Columbia  ^Hnibergitp 
in  tfje  Citp  of  J^etu  ^ovk 

College  of  ^i)j»sitianss  anb  ^urgeong 


3^ef  erence  I^ibrarp 


^aaliB  iip  Kicliart  C  Cabot 

Published  by 
HOUGHTON   MIFFLIN  COMPANY 


A  LAYMAN'S  HANDBOOK  OF  MEDICINE.     With 

Special  Reference  to  Social  Workers. 
WHAT  MEN   LIVE  BY. 
SOCIAL  WORK.     Essays  on  the  Meeting-Ground  of 

Doctor  and  Social  Worker. 


SOCIAL  WORK 


Digitized  by  tine  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/socialworkessaysOOcabo 


SOCIAL  WORK 

ESSAYS  ON  THE  MEETING-GROUND 
OF  DOCTOR  AND  SOCIAL  WORKER 


BY 

RICHARD  C.  CABOT,  M.D. 


BOSTON  AND  NEW  YORK 
HOUGHTON  MIFFLIN  COMPANY 

1919 


COPYRIGHT,    I919,    BY   RICHARD   C.    CABOT 

All  Rights  Reserved 


C  1 1  3t. 


TO 
MARY  E.   RICHMOND 

WHOSE  ILLUMINATING  BOOK  ON  "  SOCIAL  DIAGNOSIS 
MARKS  AN  EPOCH  IN  THE  DEVELOPMENT 
OF  SOCIAL   WORK 


PREFACE 

Most  writers  who  disclaim  thoroughness  are  prone 
to  describe  their  work  as  an  outhne,  a  sketch,  or  an 
introduction.  But  the  chapters  of  this  book  are  more 
like  spot-lights  intended  to  make  a  few  points  clear 
and  leaving  many  associated  topics  wholly  in  the 
dark.  Possibly  such  isolated  glimpses  may  serve 
better  than  a  clear  outhne  to  suggest  the  interest 
of  the  whole  topic.  At  any  rate,  that  is  my  hope. 
Part  of  the  same  material  has  been  used  in  lec- 
tures given  at  the  Sorbonne  in  the  early  months  of 
1918  and  pubhshed  by  Gres  &  Cie.  under  the  title 
of  Essais  de  Medecine  Sociale. 


CONTENTS 

INTRODUCTION  I  HISTORICAL  DEVELOP- 
MENT OF  SOCIAL  ASSISTANCE  IN  MEDI- 
CAL WORK vii 

Part  I :  Medical-Social  Diagnosis 

I.   THE     MEDICAL     STANDING,     DUTIES,     AND 

EQUIPMENT  OF  THE  SOCIAL  ASSISTANT       .         3 

II.   HISTORY-TAKING   BY  THE   SOCIAL  ASSIST- 
ANT   28 

III.  ECONOMIC  INVESTIGATION  BY  THE  SOCIAL 
ASSISTANT 47 

IV.  MENTAL    INVESTIGATION    BY    THE    SOCIAL 
ASSISTANT 66 

V.   MENTAL    INVESTIGATION    BY    THE    SOCIAL 

ASSISTANT,  CONTINUED 96 

VI.   THE  SOCIAL  worker's  INVESTIGATION  OF 

FATIGUE,  REST,  AND  INDUSTRIAL  DISEASE    112 

VII.   THE  SOCIAL  worker's  BEST  ALLY NA- 
TURE'S CURE  OF  DISEASE          ....    I27 

Part  II :  Social  Treatment 

VIII.    SAMPLES  OF  SOCIAL  THERAPEUTICS    .         .    I5I 
IX.   THE  MOTIVE  OF  SOCIAL  WORK      .         .         .    I76 


INTRODUCTION 

HISTORICAL  DEVELOPMENT  OF  SOCIAL  ASSISTANCE 
IN  MEDICAL  WORK 

I 

The  profession  of  the  social  worker,  which  is  the 
subject  of  this  book,  has  developed  in  the  United 
States  mostly  within  the  past  twenty-five  years. 
Probably  ten  thousand  persons  are  now  so  employed. 
It  is  known  by  various  titles  —  social  worker,  school 
nurse,  home  and  school  visitor,  welfare  worker,  hos- 
pital social  worker,  probation  officer  —  varying  ac- 
cording to  the  particular  institution  —  the  hospital, 
the  court,  the  factory,  the  school  —  from  which  it 
has  developed.  But  although  the  use  of  these  visitors 
has  been  developed  independently  by  each  institu- 
tion, and  largely  without  consciousness  of  what  was 
going  on  in  the  others,  yet  the  same  fundamental 
motive  power  has  been  at  work  in  each  case.  Because 
this  is  so,  we  shall  do  well,  at  the  outset  of  our  study 
of  home  visiting,  to  get  a  clear  conception  of  the 
common  trunk  out  of  which  various  types  of  home 
visitor  have  come  like  branches. 

Why  has  such  an  army  of  new  assistants  been 
called  into  existence?  For  this  reason :  In  the  school, 
in  the  court,  in  the  hospital,  in  the  factory,  it  has  be- 
come more  and  more  clear,  in  the  last  quarter  of  a 
century,  that  we  are  dealing  with  people  in  masses  so 


viii  INTRODUCTION 

great  that  the  individual  is  lost  sight  of.  The  individ- 
ual becomes  reduced  to  a  type,  a  case,  a  specimen  of 
a  class.  These  group  features,  this  type  of  character, 
of  course  the  individual  possesses.  He  must  be  paid 
as  "a  hand,"  he  must  be  enrolled  in  a  school  as  "a 
pupil,"  admitted  to  the  dispensary  as  "a  patient," 
summoned  before  the  court  as  "a  prisoner."  But  in 
this  necessary  process  of  grouping  there  is  always 
danger  of  dehumanization.  There  is  always  danger 
that  the  individual  traits,  which  admittedly  must  be 
appreciated  if  we  are  to  treat  the  individual  accord- 
ing to  his  deserts,  or  to  get  the  most  out  of  him,  will 
be  lost  sight  of.  We  shall  fail  to  make  the  necessary 
distinction  between  A  and  B. 

It  is  the  recognition  of  this  danger  which  has  led, 
in  the  institutions  which  I  have  mentioned,  to  the 
institution  of  the  social  worker.  Above  all  of  her  du- 
ties it  is  the  function  of  the  social  worker  to  discover 
and  to  provide  for  those  individual  needs  which  are 
otherwise  in  danger  of  being  lost  sight  of.  How  are 
these  needs  found?  In  schools,  hospitals,  factories, 
courts,  and  in  the  home  visiting  carried  out  in  con- 
nection with  them,  one  can  discern  the  two  great 
branches  of  work  which  in  the  medical  sphere  we  call 
diagnosis  and  treatment. 

Thus,  in  the  school,  it  is  for  the  individualization 
of  educational  diagnosis  and  of  educational  treat- 
ment that  the  home  visitor  exists.  The  educational 
authorities  become  aware  that  they  need  to  under- 
stand certain  children  or  all  the  children  of  a  group 


INTRODUCTION  ix 

more  in  detail  —  each  child's  needs,  difficulties, 
sources  of  retardation.  This  educational  diagnosis  is 
made  possible  through  the  home  visitor's  study  of 
the  child  in  the  home  and  out  of  school  hours.  There 
follows  a  greater  individualization  of  educational 
treatment.  The  teacher  is  enabled,  through  the  re- 
ports of  the  home  visitor,  to  fit  his  educational  re- 
sources more  accurately  to  the  particular  needs  of 
the  scholar,  so  that  they  will  do  the  most  good. 

In  the  juvenile  courts  the  judge  needs  to  under- 
stand more  in  detail  the  child's  individual  charac- 
teristics, the  circumstances,  the  temptations,  which 
preceded  and  accompanied  the  commission  of  the 
offence  which  now  brings  the  culprit  before  him. 
This  is  penological  diagnosis,  and  the  court  visitor  or 
probation  officer,  sometimes  simply  called  the  social 
worker,  makes  a  study  of  the  law-breaker  in  his 
home  and  in  relation  to  all  the  influences,  physical 
or  moral,  which  may  help  to  explain  the  commission 
of  the  particular  offence  which  has  brought  him  into 
trouble.  All  this  leads  to  the  greater  precision  of 
penological  treatment.  Understanding  more  in  detail 
why  this  particular  boy  has  committed  this  particu- 
lar theft,  how  he  differs  from  other  boys  who  have 
stolen,  the  judge  is  much  more  likely  to  choose 
wisely  those  measures  of  treatment  which  in  the 
long  run  will  do  most  to  reestabhsh  the  individual 
as  a  healthy  member  of  society. 

In  the  factory  the  object  of  the  employer  in  setting 
a  home  visitor  or  welfare  worker  at  work  is  to  create 


X  INTRODUCTION 

the  maximum  of  satisfaction  and  good  spirit  among 
his  employees,  whereby  each  will  do  his  best  work 
and  be  as  little  likely  as  possible  to  change  his  em- 
ployment. In  the  old  days,  when  shops  were  small 
and  the  employer  could  Imow  his  employees  person- 
ally, no  intermediary  such  as  a  home  visitor  was 
necessary.  The  employer  could  keep  human  touch 
with  his  men.  He  could  know  not  merely  the  amount 
of  work  done  by  each  man,  but  something  of  the  cir- 
cumstances of  his  hfe,  something  of  his  personality, 
his  adventures  and  misfortunes,  so  that  help  could 
be  extended  to  him  from  time  to  time  when  special 
need  occurred.  It  is  only  when  the  workshop  has 
grown  to  the  enormous  size  familiar  in  modern  in- 
dustrial plants  that  this  relation  of  employer  and 
employee  has  to  be  supplemented  through  the  medi- 
ating offices  of  the  home  visitor. 

It  is  this  same  process  of  evolution,  the  same  heap- 
ing-up  of  groups  till  finally  they  become  unmanage- 
able, which  has  led  to  the  employment  of  the  social 
worker  in  other  institutions.  It  is  because  the  school- 
master must  teach  so  many  that  he  can  no  longer 
know  his  pupils  and  their  famihes  individually  that 
he  has  to  employ  the  home  visitor  to  keep  him  better 
in  touch  with  them.  It  is  because  the  judge  tries  so 
many  prisoners  that  he  cannot  grasp  and  pursue  all 
the  detailed  characteristics  of  those  who  come  before 
him  for  judgment  that  he  is  compelled  to  get  them 
at  second-hand  from  a  home  visitor. 

So  finally  v\^hen  we  approach  the  reasons  for  which 


INTRODUCTION  xi 

the  medical  home  visitor  has  come  in  the  better  dis- 
pensaries of  the  United  States  to  be  an  essential 
part  of  the  institution,  we  find  that  the  unmanage- 
able increase  in  the  number  of  patients  to  be  treated 
by  the  doctor  is  one  of  the  chief  reasons  why  the 
home  visitor  has  become  necessary.  In  the  old  days 
and  in  country  practice  especially,  it  was  doubtless 
possible  for  the  doctor  to  follow  the  lives  of  his  pa- 
tients individually  as  acquaintances,  and  through 
many  years,  to  watch  the  growth  and  development 
of  famines,  to  know  their  members  as  a  friend  and 
not  merely  in  a  professional  capacity.  He  would 
meet  them  as  a  neighbor,  in  church,  in  town  meet- 
ings, in  agricultural  fairs,  in  village  sports  and  holi- 
days. Thus  he  would  touch  the  hves  of  his  fellow 
citizens  on  many  sides,  and  when  he  came  to  their 
aid  in  his  narrower  professional  capacity  he  could 
supplement  his  diagnostic  findings  and  his  thera- 
peutic resources  out  of  the  wealth  of  knowledge 
which  years  of  association  with  them  outside  the 
sick-room  had  furnished  him. 

II 

But  in  the  evolution  of  the  particular  type  of  social 
worker  who  is  the  subject  of  this  book,  the  home 
visitor  connected  with  a  dispensary,  there  are  other 
forces  besides  those  described  above,  other  motives 
besides  that  common  to  the  rise  of  all  the  types  of 
home  visitors  in  all  the  other  institutions  named. 
For  in  the  dispensary,  not  only  has  the  number  of 


xii  INTRODUCTION 

applicants  greatly  increased,  but  it  has  increased 
because  people  realized  that  there  was  much  more 
to  be  obtained  by  going  to  a  dispensary  than  was 
formerly  the  case.  The  development  of  medical  sci- 
ence and  of  the  resources  of  diagnosis  and  treatment 
which  can  now  be  put  at  the  service  of  the  dispen- 
sary patient,  has  served  to  attract  more  patients 
there.  But  these  new  resources  have  also  complicated 
the  work  of  the  physician  in  a  dispensary,  and  made 
it  more  difficult  for  him  to  remember  each  patient 
and  all  the  details  about  each  patient  as  the  physi- 
cal, chemical,  psychological,  biological  facts  emerge 
in  the  complex  ramifications  of  modern  diagnosis 
and  treatment. 

In  the  old  days  the  dispensary,  as  its  name  sug- 
gests, was  a  place  to  dispense,  to  give  out  medicine 
in  bottles  or  boxes.  The  patient  mentioned  the  name 
of  his  ailment,  the  corresponding  remedy  was  given. 
It  was  a  quick  and  simple  business  —  no  individual 
study,  no  prolonged  labor  was  necessary.  Moreover, 
one  dealt  only  with  a  clearly  defined  class,  the  poor. 
There  was  no  danger  that  the  numbers  applying  for 
relief  would  swamp  the  institution  or  make  it  im- 
possible for  the  dispenser  to  do  his  work  properly. 

But  within  the  past  quarter  of  a  century  the  dis- 
pensary, especially  in  the  United  States,  has  received 
a  new  idea,  an  access  of  fresh  life.  Largely  because  it 
has  become  associated  with  universities  and  been 
used  as  an  instrument  of  medical  teaching,  the  influ- 
ence of  scientific  medicine  has  begun  to  be  felt  there. 


INTRODUCTION  xiii 

This  influence  has  enlarged  and  remodelled  the  dis- 
pensary in  two  respects.  First  it  has  compelled  the 
introduction  of  modern  accurate  methods  of  diag- 
nosis, instruments  of  precision,  time-consuming  pro- 
cesses of  examination,  specialization  of  labor,  and 
subdivision  of  function,  for  the  skilful  application  of 
these  methods.  The  dispensary  physician  is  no  longer 
content  to  treat  a  headache  or  a  cough  as  an  entity, 
to  dispense  this  or  that  drug  as  the  remedy  for  such 
a  symptom.  He  must  discover  if  possible  the  under- 
lying disease,  and,  moreover,  the  individual  consti- 
tution and  life-history  in  the  course  of  which  the 
patient's  complaint  now  rises  for  the  moment  to  the 
surface  like  a  fleck  of  white  foam  on  an  ocean  wave. 
But  how  is  the  physician  to  gain  this  radical  and  de- 
tailed knowledge  of  his  patient's  life  outside  the  dis- 
pensary and  enveloping  the  particular  complaints 
for  which  he  now  demands  relief? 

His  difTiculties  are  only  increased  when  diagnosis 
is  complete  and  he  turns  to  the  labors  of  treatment. 
For  with  the  advance  of  modern  medical  science 
there  are  left  now  but  few  physicians  who  believe 
that  disease  can  often  be  cured  by  a  drug.  It  is  recog- 
nized by  the  better  element  of  the  medical  profession 
all  over  the  world  that  only  in  seven  or  eight  out  of 
about  one  hundred  and  fifty  diseases  clearly  dis- 
tinguished in  our  textbooks  of  medicine,  have  we  a 
drug  with  any  genuine  pretensions  to  cure.  What  is 
to  take  the  place  of  drugs  in  dispensary  treatment? 
In  hospital  patients  we  have  the  hospital  regime,  the 


xiv  INTRODUCTION 

unrivalled  therapeutic  values  of  rest  in  bed,  the 
services  of  the  nurses;  but  in  dispensary  practice  all 
this  is  unpossible.  What  is  to  take  its  place? 

For  a  good  many  years  this  question  remained  un- 
answered in  American  dispensaries,  and  as  a  result 
thereof  there  developed  the  pernicious  habit  of  giv- 
ing drugs  no  longer  beheved  in  by  the  physician,  the 
custom  of  giving  what  we  call  placebos^  remedies 
known  to  be  without  any  genuine  effect  upon  the 
disease,  but  beheved  to  be  justified  because  the  pa- 
tient must  be  given  something  and  because  we  know 
not  what  else  to  do  or  how  else  to  satisfy  him. 

Ill 

It  was  at  this  very  unfortunate  and  undignified 
stage  in  the  development  of  our  dispensary  work  in 
America  that  we  received  priceless  help  from  France, 
help  which  I  am  all  the  more  anxious  to  acknowledge 
to-day  because  it  has  not,  I  think,  been  fully  appre- 
ciated in  the  past.  We  in  America  have  not  given  to 
France  the  full  expression  of  the  gratitude  which,  for 
her  services  in  the  field  of  medicine,  as  in  even  more 
important  phases  of  our  national  life,  it  is  to-day 
particularly  fitting  that  we  should  utter.  The  timely 
contribution  made  by  France  at  this  halting  and 
unsatisfactory  stage  in  the  evolution  of  our  dispen- 
saries came  through  the  work  of  the  great  Dr. 
Calmette,  of  Lille. 

Calmette's  introduction  of  the  anti-tuberculosis 
dispensary  as  a  focal  centre  of  the  fight  against  tu- 


INTRODUCTION  xv 

berculosis  contained  among  other  important  provi- 
sions the  institution  of  the  visite  domiciliaire.  The 
functions  of  the  person  making  this  visit  were  not 
precisely  the  same  as  those  of  the  social  worker  whom 
I  am  describing  in  this  book,  but  the  latter  may 
truly  be  said  to  have  grown  out  of  the  former,  nour- 
ished by  some  contributing  elements  from  other 
sources.  So  far  as  I  know,  Calmette  was  the  first  to 
see  that  in  the  struggle  of  the  dispensary  against  this 
particular  disease,  tuberculosis,  it  is  essential  to 
make  contact  with  the  home,  and  to  treat  the  dis- 
ease there  as  well  as  at  the  dispensary  itself.  In  Cal- 
mette's  view  the  function  of  the  visite  domiciliaire 
was  an  outgrowth  of  his  bacteriological  training 
and  his  bactericidal  plan  for  treating  tuberculo- 
sis. The  home  visitor  was  a  part  of  the  plan  of  anti- 
sepsis, a  method  of  destroying  the  bacteria  through 
disinfection  and  sterilization  of  the  premises  and  of 
the  patient's  Hnen.  In  America  the  work  of  the  home 
visitor  in  cases  of  tuberculosis  has  been  concerned 
less  with  the  disinfection  and  bactericidal  procedures 
than  with  the  positive  measures  of  hygiene,  such  as 
the  better  housing  of  the  patient,  better  nutrition, 
better  provision  for  sunlight  and  fresh  air,  and  above 
all  instruction  of  the  patient  as  to  the  nature  of  his 
disease  and  the  methods  to  be  pursued  in  combating 
it.  But  the  great  debt  which  we  owe  to  Calmette  was 
the  linkage  of  the  dispensary  and  the  home  by  means 
of  the  home  visitor.  In  America  we  have  applied  this 
principle,  outside  the  field  of  tuberculosis,  to  all 


xvi  INTRODUCTION 

other  diseases,  and  we  have  broadened  the  field  of 
work  assigned  to  the  social  worker.  Nevertheless,  the 
idea  was  primarily  Calmette's. 

There  was  another  leading  idea  of  Calmette's 
which  we  have  followed  first  in  relation  to  tubercu- 
losis, later  in  deahng  with  other  diseases.  Like  Cal- 
mette  we  have  stopped  wholesale  drugging,  and  put 
our  trust  in  those  scientific  hygienic  procedures 
which  C2ny  out  our  knowledge  of  the  nature  of  the 
disease  which  we  are  combating.  Calmette's  meas- 
ures have  the  tone  and  the  point  of  view  of  preven- 
tive medicine,  and  of  that  sound  science  which  we 
have  learned  to  associate  with  the  Pasteur  Institute 
and  all  that  development  of  medicine  which  took  its 
rise  from  Pasteur. 

The  focussing  of  interest  upon  a  single  disease 
which  began,  so  far  as  I  know,  ■v,dth  Calmette's  anti- 
tuberculosis dispensaries,  has  been  fruitful  in  many 
ways.  In  the  first  place,  it  has  enabled  science  once 
more  to  conquer  by  dividing  the  fields  to  help  hu- 
manity by  devoting  itself  to  a  single  manageable 
task.  Like  others  of  Calmette's  ideas,  this  isolation 
of  a  single  disease  for  group  treatment  in  dispen- 
saries has  been  followed  in  fields  with  which  he  never 
concerned  himself.  Thus  we  have  had  special  classes 
for  cases  of  heart  disease,  for  diabetes,  for  s^^hihs, 
for  the  digestive  disturbances  of  infancy,  and  for 
pohomyelitis.  A  valuable  measure  of  success  has 
come  in  each  of  these  diseases  through  the  concen- 
tration of  attention,  at  a  special  day  and  special  hour 


INTRODUCTION  xvii 

by  a  special  group  of  physicians  and  assistants,  upon 
one  disease  at  a  time.  We  have  even  used  class  meth- 
ods and  taught  the  patients  in  groups  as  scholars 
are  grouped  and  taught  at  school. 

But  there  has  come  another  signal  advantage  in 
the  point  of  view  adopted  by  Calmette  in  his  dis- 
pensary campaign  —  the  point  of  view,  namely,  of 
pubhc  health  and  public  good.  It  has  freed  us  from 
the  limitations  contained  in  the  old  idea  that  a  dis- 
pensary is  an  institution  concerned  solely  with  the 
poor.  Tuberculosis,  of  course,  like  every  other  in- 
fectious disease  pays  but  little  respect  to  distinc- 
tions of  property.  From  the  point  of  view  of  the 
State  a  tuberculous  individual  is  as  dangerous  to 
others  and  a  cured  tuberculous  patient  is  as  valu- 
able as  a  possible  asset  to  the  State,  whether  his  in- 
come is  above  or  below  a  certain  figure,  whether,  in 
other  words,  he  is  inside  or  outside  the  imaginary 
group  sometimes  called  the  poor.  From  the  institu- 
tion of  tuberculosis  dispensaries  with  their  home 
visitors  in  America,  the  poverty  of  the  individual 
ceased  to  be  a  necessary  badge  for  admission.  Espe- 
cially since  many  of  our  dispensaries  have  been 
instituted  and  maintained  by  the  State,  and  there- 
fore are  paid  for  by  all  its  citizens  in  their  taxes, 
any  one  so  unfortunate  as  to  acquire  tuberculosis, 
or  be  suspected  of  it,  feels  himself  wholly  justified 
in  seeking  help  at  a  State-maintained  tuberculosis 
dispensary.  In  this  respect,  as  in  many  others,  the 
campaign  against  tuberculosis  has  had  a  value  far 


xviii  INTRODUCTION 

greater  than  its  measure  of  success  in  checldng  that 
disease.  It  has  introduced  methods  which  were  appU- 
cable  outside  the  field  of  tuberculosis.  One  of  these, 
as  I  have  already  said,  was  the  utilization  of  the 
home  visitor.  A  second  was  the  disregarding  of  prop- 
erty fines.  A  third  was  the  frank  and  confident  reli- 
ance upon  scientific  measures  and  the  relegation  of 
eclecticism  and  quackery  to  the  hands  of  those  who 
make  no  pretence  at  scientific  education  or  honest 
deafings  with  the  pubhc. 

IV 

I  must  speak  at  this  point  of  another  great  French 
contribution  towards  the  occupation  which  in  its 
fully  developed  state  we  now  call  social  work.  I 
mean  that  which  at  present  receives  ordinarily  the 
name  of  the  "  QEuvre  Grancher."  Grancher  proceeded 
upon  the  same  sound  bacteriological  foundations 
which  guided  Cahnette.  Since  children  are  especially 
susceptible  to  tuberculous  infection  (though  they 
rarely  show  alarming  signs  of  it  till  later  years),  he 
planned  the  separation  of  children  from  the  neigh- 
borhood of  tuberculous  parents  or  other  tuberculous 
persons  as  an  essential  measure  for  preventing  con- 
tagion. I  am  not  concerned  now  with  the  enormous 
benefit  derived  by  the  forces  struggling  against  tu- 
berculosis from  this  insight  of  Grancher's,  nor  with 
the  part  which  it  has  played  in  such  success  as  that 
fight  has  already  attained  in  the  United  States  and 
elsewhere.  What  interests  me  particularly  in  connec- 


INTRODUCTION  xix 

tion  with  the  topic  of  this  book,  is  that  the  pro- 
cedures suggested  by  Grancher  led  the  physicians 
who  came  in  contact  with  the  tuberculous  individ- 
ual in  a  dispensary  to  extend  their  interest  to  other 
persons  who  did  not  present  themselves  at  the  dis- 
pensary as  patients.  It  is  not  obvious  at  first  sight 
how  great  a  transforming  principle  is  thereby  intro- 
duced. Hitherto  the  doctor  had  been  passive  in  his 
activities  at  the  dispensary.  He  had  concerned  him- 
self with  such  patients  as  chanced  to  appear  there. 
He  had  never  taken  the  active  or  aggressive  attitude, 
searching  for  possible  patients  among  those  who  had 
made  no  attempt  to  avail  themselves  of  his  services. 
Now  he  goes  to  find  patients. 

This  is  an  epoch-making  change.  The  physician 
becomes  henceforth  not  merely  a  person  who  stands 
ready  to  treat  disease  when  the  accidental  and  incal- 
culable forces  of  custom,  hearsay,  and  natural  pro- 
pinquity bring  the  patient  to  him.  He  becomes  now 
a  person  who  actively  wars  against  disease,  who 
searches  it  out  wherever  it  may  be  found.  Thus  he 
approaches  for  the  first  time  the  possibihty  of  truly 
preventive  action,  the  possibihty  of  killing  disease  in 
its  infancy  or  preventing  its  birth.  For  it  is  well 
known  that  preventive  action  in  relation  to  disease 
is  well-nigh  impossible  if  we  are  forced  or  accus- 
tomed to  wait  until  the  disease  has  made  such  prog- 
ress that  the  patient  himself  is  aware  of  it  and 
forced  by  its  ravages  to  ask  medical  aid.  Ordinarily 
the  patient  seeks  the  physician  only  when  he  has 


XX  INTRODUCTION 

broken  down.  From  the  point  of  view  of  public 
health  and  pubhc  good,  this  is  grievously  late,  far 
too  late.  It  is  as  if  one  inspected  an  elevator  only 
after  it  had  fallen  and  killed  or  maimed  its  passen- 
gers, instead  of  inspecting  it  at  regular  intervals  so 
as  to  prevent  its  breaking  down. 

In  this  series  of  aggressive  steps  in  the  campaign 
against  tuberculosis  whereby  one  seeks  out  possibly 
infected  children,  brings  them  to  a  dispensary  for 
examination,  and  separates  them  from  their  infected 
parents  or  house-mates,  the  social  worker  is  the  all- 
important  executive.  She  finds  the  children,  brings 
them  or  has  them  brought  to  the  dispensary,  and 
sees  that  financial  aid  or  other  assistance  is  given  so 
as  to  carry  out  the  isolation  demanded  by  our  bac- 
teriological loiowledge  of  the  disease. 

V 

As  far  back  as  1895  the  reforms  introduced  by  Cal- 
mette  and  Grancher  in  the  field  of  tuberculosis  had 
begun  to  modify  and  improve  the  treatment  given  in 
our  dispensaries,  not  only  to  tuberculosis  but  to  all 
other  diseases.  Especially  it  had  favored  the  growth 
of  home  visiting,  at  first  for  the  specific  ends  for 
which  it  was  designed  by  Calmette  and  Grancher, 
but  later  for  the  prosecution  of  various  related  pur- 
poses which  the  very  process  of  visiting  brought  to 
light.  Not  only  in  tuberculosis,  but  in  other  diseases, 
it  was  soon  found  that  a  knowledge  of  home  condi- 
tions and  of  the  family  was  essential  for  the  treat- 


INTRODUCTION  xxi 

ment  of  the  single  patient  who  chanced  to  appear  at 
the  dispensary. 

It  was  my  good  fortune  during  the  ten  years  pre- 
ceding 1905  to  work  as  a  member  of  the  board  of 
directors  of  a  private  charitable  society  caring  for 
children  deserted  by  their  parents,  orphaned,  cruelly 
treated;  also  for  children  whose  parents  found  them 
unmanageable  or  for  children  who  had  special  diffi- 
culties in  getting  on  at  school.  The  work  of  this  so- 
ciety brought  to  me  detailed  knowledge  of  the  life- 
histories  of  a  good  many  children.  I  watched  the 
careful  studies  made  by  the  paid  agents  of  the  soci- 
ety into  the  character,  disposition,  antecedents,  and 
record  of  the  child,  his  physical  condition,  his  inher- 
itance, his  school  standing.  I  noticed  during  these 
years  how  the  agents  of  this  society,  to  whom  the 
child  was  first  brought  by  its  parents  or  by  others 
interested  in  it,  utilized  to  the  full  the  knowledge 
and  resources  of  others  outside  its  own  field;  how, 
for  example,  they  enlisted  the  full  cooperation  of  the 
child's  school-teacher,  secured  facts  and  advice  from 
the  teacher,  and  agreed  with  her  upon  a  plan  of 
action  to  be  carried  out  both  by  her  and  by  the 
home  visitor  in  concert.  Moreover,  I  saw  how  physi- 
cians were  consulted  about  the  child,  and  how  their 
advice  and  expert  skill  contributed  something  quite 
different  from  that  obtained  from  the  teacher  or  that 
gained  by  the  home  visitor  herself.  The  priest  or 
clergyman  connected  with  the  family  was  also  asked 
for  aid,  and  sometimes  could  give  very  great  help, 


xxii  INTRODUCTION 

difTering  essentially  in  kind  from  that  given  by  the 
teacher  or  by  the  doctor.  If  there  were  problems  in- 
volving poverty  on  the  part  of  the  parents,  other 
societies  concerning  themselves  particularly  with 
the  problems  of  financial  rehef  were  asked  to  aid,  in 
order  that  indirectly  the  help  given  to  the  parents 
might  make  itself  felt  in  the  better  condition  of  the 
child.  Sometimes  free  legal  advice  w^as  obtained 
from  the  legal  aid  society  formed  for  the  purpose  of 
giving  such  advice  to  those  who  were  unable  to  pay 
for  it. 

As  I  watched  the  application  of  this  method  over 
a  period  of  a  good  many  years  and  in  the  case  of  a 
great  many  children,  I  saw  a  good  many  failures  in 
addition  to  some  most  encouraging  successes.  But 
what  most  of  all  impressed  itself  upon  me  was  the 
method,  the  focussing  of  effort  on  the  part  of  many 
experts  upon  the  needs  of  a  single  child,  the  cooper- 
ation of  many  W'hose  gifts  and  talents  varied  as 
widely  as  their  uiterests,  to  the  end  that  a  single 
unfortunate  child  might  receive  benefit  far  beyond 
what  the  resources  of  any  single  individual,  no  mat- 
ter how  well  intentioned,  could  secure. 

I  have  said  that  the  doctor  was  a  member  of  the 
group  whose  efforts  were  focussed  upon  the  needs  of 
a  single  child,  but  he  was  never  a  very  closely  con- 
nected member  of  this  group.  A  few  charitably  ui- 
clined  physicians,  personal  friends  of  those  directing 
the  charities,  were  called  upon  again  and  again  to 
help  out  in  mdividual  cases  by  examinmg  a  child,  by 


INTRODUCTION  xxiii 

giving  advice  over  the  telephone  or  otherwise. 
Through  the  free  hospitals  and  dispensaries  help 
was  also  obtained  for  the  physical  needs  of  persons 
who  had  come  to  the  notice  of  the  different  chari- 
table associations  by  reason  of  economic  need  or 
other  misfortune.  But  the  medical  charities,  the  hos- 
pitals, dispensaries,  convalescent  homes,  and  the 
benevolence  of  individual  physicians  were  not  well 
connected  with  the  group  of  charitable  associations 
which  I  have  been  referring  to  above. 

At  this  period,  in  1893  and  1894, 1  had  been  work- 
ing for  some  years  as  a  dispensary  physician,  con- 
cerning myself  chiefly  with  perfecting  the  methods 
of  diagnosis  in  a  dispensary,  so  that  the  patient  could 
obtain  there  a  diagnosis  as  correct  and  scientifically 
founded  as  he  could  obtain  from  a  private  physician. 
But  in  the  course  of  these  efforts  for  a  complete  and 
exact  diagnosis  which  should  do  justice  to  the  actual 
needs  of  the  patient,  I  found  myself  blocked.  I 
needed  information  about  the  patient  which  I  could 
not  secure  from  him  as  I  saw  him  in  the  dispensary 
—  information  about  his  home,  about  his  lodgings, 
his  work,  his  family,  his  worries,  his  nutrition.  I  had 
no  time  —  no  dispensary  physician  had  time  —  for 
searching  out  this  information  through  visiting  the 
patient's  home.  Yet  there  was  no  one  else  to  do  it. 
My  diagnoses,  therefore,  remained  shpshod  and  su- 
perficial—  unsatisfactory  in  many  cases.  Both  in 
these  cases  and  in  the  others  where  no  diagnosis 
was  possible  from  the  physical  examination  alone,  I 


xxiv  INTRODUCTION 

found  myself  constantly  baffled  and  discouraged 
when  it  came  to  treatment.  Treatment  in  more  than 
half  of  the  cases  that  I  studied  during  these  years 
of  dispensary  work  involved  an  understanding  of  the 
patient's  economic  situation  and  economic  means, 
but  still  more  of  his  mentality,  his  character,  his 
previous  mental  and  industrial  history,  all  that  had 
brought  him  to  his  present  condition,  in  which  sick- 
ness, fear,  worry,  and  poverty  were  found  inextrica- 
\^  bly  mingled.  Much  of  the  treatment  which  I  pre- 
scribed was  obviously  out  of  the  patient's  reach.  I 
would  tell  a  man  that  he  needed  a  vacation,  or  a 
woman  that  she  should  send  her  children  to  the 
country,  but  it  was  quite  obvious,  if  I  stopped  to  re- 
flect a  moment,  that  they  could  not  possibly  carry 
out  my  prescription,  yet  no  other  filled  the  need.  To 
give  medicine  was  often  as  irrational  as  it  would  be 
to  give  medicine  to  a  tired  horse  dragging  uphill  a 
weight  too  great  for  him.  What  was  needed  was  to 
unload  the  wagon  or  rest  the  horse;  or,  in  human 
terms,  to  contrive  methods  for  helping  the  individual 
to  bear  his  own  burdens  in  case  they  could  not  be 
lightened.  Detailed  individual  study  of  the  person, 
his  history,  circumstances,  and  character  were  fre- 
quently essential  if  one  was  to  cure  him  of  a  head- 
ache, a  stomach-ache,  a  back-ache,  a  cough,  or  any 
other  apparently  trivial  ailment. 

Facing  my  own  failures  day  after  day,  seeing  my 
diagnoses  useless,  not  worth  the  time  that  I  had 
spent  in  making  them  because  I  could  not  get  the 


INTRODUCTION  xxv 

necessary  treatment  carried  out,  my  work  came  to 
seem  almost  intolerable.  I  could  not  any  longer  face 
the  patients  when  I  had  so  little  to  give  them.  I  felt 
like  an  impostor. 

Then  I  saw  that  the  need  was  for  a  home  visitor 
or  a  social  worker  to  complete  my  diagnosis  through 
more  careful  study  of  the  patient's  malady  and  eco- 
nomic situation,  to  carry  out  my  treatment  through 
organizing  the  resources  of  the  community,  the 
charity  of  the  benevolent,  the  forces  of  different 
agencies  which  I  had  previously  seen  working  so 
harmoniously  together  outside  the  hospital.  Thus  I 
established  in  1905  a  full-time,  paid  social  worker  at 
the  Massachusetts  General  Hospital,  to  cooperate 
with  me  and  the  other  physicians  in  the  dispensary, 
fnst  in  deepening  and  broadening  our  comprehen- 
sions of  the  patients  and  so  improving  our  diagnoses, 
and  second  in  helping  to  meet  their  needs,  economic, 
mental,  or  moral,  either  by  her  own  efforts,  or 
through  calling  to  her  aid  the  group  of  alUes  already 
organized  in  the  city  for  the  rehef  of  the  unfortunate 
wherever  found.  To  bring  the  succor  of  these  alhes 
into  the  hospital  and  apply  it  to  the  needs  of  my 
patients  as  they  were  studied  jointly  by  doctor  and 
home  visitor,  was  the  hope  of  the  new  work  which 
I  estabhshed  at  that  time. 

In  the  thirteen  years  which  have  elapsed  since 
this  period,  about  two  hundred  other  hospitals  in  the 
United  States  have  started  social  work,  some  of 
them  employing  forty  or  fifty  paid  social  workers  for 


xxvi  INTRODUCTION 

the  needs  of  a  single  hospital.  Unpaid  volunteer  work 
has  always  been  associated  with  that  of  the  paid 
workers  in  the  better  hospitals. 

I  should  mention,  in  closing  this  chapter,  three 
forms  of  medical-social  work  which  had  been  under- 
taken previous  to  1905,  and  which  were  more  or 
less  hke  the  work  which  I  have  just  described, 
though  not  identical  with  it : 

(1)  The  after-care  of  the  patients  discharged  as 
cured  or  convalescent  from  English  hospitals  for  the 
insane  (1880).  The  visitors  employed  in  this  work 
followed  the  patients  in  their  homes  and  reported 
back  to  the  institution  which  they  had  left.  Their 
labors  were  directed  chiefly  to  the  prevention  of  re- 
lapses through  the  continuation  in  the  home  of  the 
advice  and  regime  advised  by  the  hospital  physician 
and  previously  carried  out  in  the  institution. 

(2)  The  work  of  the  Lady  Almoners  long  existing 
in  the  English  hospitals  had  begun  about  the  time 
that  I  started  medical-social-service  work  in  America, 
to  change  its  character  so  as  to  be  more  like  the  lat- 
ter. Originally  the  purpose  of  the  Lady  Almoners 
was  to  investigate  the  finances  of  hospital  patients  in 
order  to  prevent  the  hospital  from  being  imposed 
upon  by  persons  who  were  able  to  pay  something, 
but  who  represented  themselves  as  destitute  and 
therefore  fit  subjects  for  the  aid  of  a  charitable  hos- 
pital. Gradually,  however,  the  Lady  Almoners  had 
begun  to  be  interested  in  the  patients  as  well  as  in 
the  hospital  funds,  and  had  begun  to  labor  for  the 


INTRODUCTION  xxvii 

patients'  benefit  as  well  as  for  the  hospital's.  This 
brought  them  near  to  the  idea  of  hospital  social 
service  as  practised  in  this  country  since  1905. 

(3)  The  visiting  nurses  or  public  health  nurses, 
employed  by  a  Board  of  Health  or  by  private  agen- 
cies for  the  care  of  contagious  diseases  in  the  home 
and  also  for  the  nursing  of  the  sick  poor  whatever 
their  malady,  have  found  it  more  and  more  difTicult 
in  late  years  to  confine  their  work  wholly  to  physi- 
cal aid.  They  have  been  forced  to  take  account  of 
the  patients'  economic,  mental,  and  moral  difficul- 
ties, to  extend  their  work  beyond  the  field  of  nurs- 
ing proper,  and  thus  to  approach  very  closely  to  the 
field  of  the  social  worker.  It  is  my  own  belief  that 
the  frontier  separating  visiting  nurse  and  medical 
social  worker  should  be  rubbed  out  as  rapidly  as 
possible,  until  the  two  groups  are  fused  into  one. 
The  visiting  nurse  must  study  the  economic  and 
mental  sides  of  the  patients'  needs,  and  the  social 
worker  must  learn  something  of  medicine  and  nurs- 
ing. Then  the  two  groups  will  be  fused  into  one,  as 
indeed  they  are  fast  fusing  at  the  present  time. 


SOCIAL  WORK 

PART  I 
Medical-Social  Diagnosis 


SOCIAL  WORK 

CHAPTER  I 

THE  MEDICAL  STANDING,  DUTIES,  AND  EQUIPMENT 
OF  THE  SOCIAL  ASSISTANT 

I  HAVE  said  in  the  Introduction  that  home  visiting 
may  easily  and  properly  spring  up  in  connection 
with  various  institutions ;  for  example,  in  connection 
with  the  schools,  courts,  or  factories  of  the  city  as 
well  as  with  the  dispensaries.  But  it  is  essential  in 
home  visiting,  no  matter  what  institution  it  is  con- 
nected with,  that  the  social  assistant  should  be  dis- 
tinctly recognized  as  part  of  the  machinery  of  that 
institution,  or,  in  other  words,  as  one  of  the  means 
by  which  that  institution  does  its  work.  If  she  is 
connected  with  the  schools,  she  should  be  a  part  of 
the  school  system  alone,  not  responsible  to  a  Board 
of  Health  or  to  any  other  outside  agency. 

So  in  the  type  of  home  visiting  which  now  partic- 
ularly concerns  us,  it  is  essential  to  make  it  clear 
from  the  outset  that  the  social  worker  is  a  part  of  the 
medical  organization.  She  is  one  of  the  means  for 
diagnosis  and  treatment.  All  that  she  does  from  the 
moment  when  she  first  scrapes  acquaintance  with 
the  patient  is  to  be  connected  with  the  condition  of 
the  patient's  health.  She  is  not  to  pursue  independ- 


4  SOCIAL  WORK 

ent  sociological  or  statistical  inquiries.  She  is  not  to 
be  the  agent  of  any  other  non-medical  society.  It 
is  unfortunate  even  if  her  salary  should  be  paid 
from  any  source  other  than  the  medical  institution 
itself. 

There  are  great  advantages  in  this  apparently  for- 
mal and  obvious  point  of  connection.  In  the  first 
place  the  medical  method  of  approach  to  close  rela- 
tions, to  friendly  relations,  with  a  group  of  people, 
is  decidedly  the  easiest.  Persons  who  may  be  suspi- 
cious or  resentful  of  our  approach  if  we  appear  pri- 
marily as  investigators,  or  primarily  as  persons  con- 
cerned with  economic  or  moral  control,  will  welcome 
the  visitor  if  she  appears  as  the  arm,  the  cordially 
extended  hand,  of  the  medical  institution  where 
they  have  already  found  welcome  and  relief.  I  know 
well  that  charity  organization  workers,  court  workers 
and  others  may  establish  just  as  close  a  relation  with 
their  clients  in  the  end  as  is  possible  for  the  medical 
social  worker.  But  the  start  is  harder  and  needs  more 
experience.  Because  disease  is  the  common  enemy  of 
mankind,  all  sorts  and  conditions  of  men  are  in- 
stinctively drawn  together  when  it  becomes  neces- 
sary to  resist  the  attacks  of  disease  as  the  enemy  of 
the  human  family.  Members  of  a  family  may  dis- 
agree about  many  matters,  and  may  be  far  from 
congenial  with  one  another  in  ordinary  times  and 
upon  ordinary  subjects,  but  will  draw  together  into 
the  closest  kind  of  unity  if  any  one  attacks  the  family, 
accuses  or  criticises  the  family.  So  human  beings  of 


STANDING,  DUTIES,  EQUIPMENT     5 

widely  different  environment,  taste,  economic  status, 
heredity,  may  find  it  quite  easy  to  begin  and  to 
maintain  friendly  relations  when  that  which  brings 
them  together  is  their  common  interest  in  the  strug- 
gle against  disease.  It  is,  indeed,  almost  too  easy 
to  get  friendly  with  people  when  they  are  suffering 
physically  and  we  are  endeavoring,  however  lamely, 
to  bring  them  relief. 

The  medical  avenue  of  approach,  then,  the  plan 
and  hope  of  establishing  intimate  relations  with  a 
person  or  a  family  while  we  are  trying  to  give  them 
medical  assistance,  offers  incomparable  advantages. 
These  advantages  become  clearer  still  if  we  compare 
them  with  the  special  difficulties  which  arise  if  one 
tries  to  begin  an  acquaintanceship  with  financial  in- 
quiries or  with  moral  investigations.  People  who  will 
agree  on  everything  else  will  quarrel  on  money  mat- 
ters. There  is  nothing  that  so  easily  leads  to  friction, 
suspicion,  and  unfriendliness,  as  the  interview  in 
which  one  is  trying  to  make  out  whether  people  are 
speaking  the  truth,  the  whole  truth,  and  nothing 
but  the  truth,  in  relation  to  their  income  and  expen- 
diture. This  matter  very  naturally  seems  to  people 
their  own  business.  They  quite  naturally  resent  in- 
quiries on  such  matters  by  strangers.  They  feel  at- 
tacked and  in  defence  they  are  apt  to  conceal  or  color 
the  truth.  And  yet,  if  a  friendly  relation  has  first 
been  established  through  the  patient's  recognition 
of  our  genuine  desire  to  help  his  physical  difficulties, 
the  financial  inquu-ies  which  make  a  necessary  part 


6  SOCIAL  WORK 

of  the  home  visitor's  work  can  much  more  easily  fol- 
low. One  has  to  understand  what  money  is  available 
in  order  to  make  the  best  plans  for  nutrition,  for 
home  hygiene,  for  rest  and  vacation  —  all  of  which 
naturally  form  part  of  our  medical  interest.  I  wish  to 
make  quite  clear  here  my  appreciation  that  good 
social  workers  never  begin  their  relationships  with 
a  client  by  assuming  a  moral  fault  on  his  part  and 
never  push  the  economic  questionnaire  into  the  first 
interview.  All  I  wish  to  point  out  is  that  it  is  perhaps 
easier  for  the  medical  social  worker  than  for  others 
to  avoid  these  blunders. 

At  the  outset  of  a  relationship  which  aims  to  be 
friendly,  investigations  which  start  with  the  assump- 
tion that  there  has  been  some  moral  fault  or  weak- 
ness in  those  whom  we  wish  to  help  are  even  worse 
than  financial  inquiries.  The  instant  that  the  social 
worker  finds  herself  in  the  position  of  a  moral  critic, 
it  becomes  next  to  impossible  that  a  friendly  relation 
not  hitherto  established,  shall  be  built  up  from  the 
beginning.  Late  in  the  course  of  a  friendship  estab- 
lished long  before,  moral  help,  even  moral  criticism, 
may  be  welcome.  But  it  cannot  often  or  easily  be 
one  of  the  topics  of  conversation,  one  of  the  points  of 
investigation,  in  the  early  stages  of  what  we  hope  to 
make  a  friendly  relation. 

Everything  stands  or  falls  with  this.  We  cannot 
even  teach  hygiene,  we  cannot  even  make  medical 
principles  clear  unless  we  have  succeeded  to  some 
extent,  perhaps  without  any  merit  on  our  part,  per- 


STANDING,  DUTIES,  EQUIPMENT     7 

haps  through  extraordinary  good  fortune,  in  acquir- 
ing a  genuine  Uking  for  the  person  whom  we  want  to 
help.  Once  that  is  attained,  we  can  work  miracles. 
But  if  it  is  wholly  lacking,  we  cannot  count  upon 
accomplishing  the  simplest  interchange  of  accurate 
information;  we  cannot  achieve  the  most  elemental 
hygienic  instruction. 

But  there  is  another  signal  advantage  in  the  medi- 
cal point  of  approach  to  a  relationship  which,  as  I 
have  said,  must  be  friendly  in  fact,  not  merely  in 
name,  if  it  is  to  succeed  in  any  of  its  ulterior  objects. 
When  the  social  worker  begins  the  difficult  task  of 
acquiring  her  influence  in  a  family,  she  starts  with  a 
great  deal  in  her  favor  if  she  appears  in  the  home  as 
the  agent  of  the  physician.  He  has  prestige.  By  reason 
of  his  profession,  by  reason  of  the  institution  which 
he  represents,  by  reason  of  confidence  already  estab- 
lished by  him  in  the  patients'  friends  and  neighbors, 
the  new  family  is  ready  to  have  confidence  in  him. 
He  is  not  thought  to  have  any  axe  to  grind.  He  is 
assumed  to  be  genuine  in  his  desire  of  helpfulness. 
Therefore  any  one  who  appears  in  his  name,  as  his 
assistant,  has  a  great  deal  in  her  favor,  especially 
when  compared  with  the  visitors  of  societies  which 
might  be  supposed  to  begin  with  economic  or  moral 
suspicions  about  the  family.  If  the  visitor  appears  in 
the  home  with  the  prestige  of  a  medical  institution 
enhancing  the  value  of  her  own  personahty,  she  has 
a  very  definite  advantage. 


8  SOCIAL  WORK 

Light  on  the  severity  of  illness 

I  have  said  that  it  is  essential  to  the  success  of  a 
medical  visitor's  work  that  she  should  be  part  of  the 
medical  machine,  acknowledged  as  the  doctor's 
agent,  concerned  wholly  with  helping  to  carry  out 
his  plans.  But  we  must  ask  now,  what  part?  And  the 
answer  is  that  the  social  worker  is  an  assistant  to  the 
physician  both  in  diagnosis  and  in  treatment.  I  will 
begin  with  an  account  of  what  she  is  to  do  as  his 
assistant  in  diagnosis. 

She  is  to  discover,  so  far  as  she  can,  what  the  dis- 
ease is,  how  much  the  disease  is,  and  why  it  is.  I  do 
not  mean,  of  course,  that  she  is  to  ape  the  doctor's 
scientific  investigations,  that  she  is  to  use  instru- 
ments of  precision,  or  to  trj^  to  prescribe  medicines. 
But  she  is  to  help  the  physician  in  some  of  the  fol- 
lowing ways : 

He  is  often  very  much  at  a  loss  to  be  sure  how  bad 
the  patient's  symptoms  really  are,  how  much  the 
patient  suffers,  how  serious  the  case  is.  The  social 
worker  is  often  able  to  help  in  discovering  why  the 
patient  really  came  to  the  dispensar3%  discovering, 
perhaps,  that  the  reason  is  such  as  to  show  that  the 
malady  is  really  a  trifling  one.  She  may  find,  for  in- 
stancC;  that  the  patient  has  come  merely  because 
her  husband  had  to  come,  an^^'ay,  and  she  thought 
she  would  get  the  benefit  of  whatever  there  was  to 
be  had  in  the  way  of  medical  assistance  at  the  dis- 
pensar>%  even  though,  unless  her  husband  had  been 


STANDING,  DUTIES,  EQUIPMENT     9 

going,  anyway,  it  would  not  have  occurred  to  her 
to  make  the  independent  visit  upon  her  own  account. 
Or,  again,  the  visit  may  be  due  chiefly  to  curiosity, 
especially  if  the  dispensary  has  been  newly  estab- 
lished or  has  added  some  new  features  to  its  methods 
of  diagnosis  and  treatment.  These  facts  are  passed 
along  from  person  to  person;  the  person  hearing  of 
them  may  appear  as  a  patient  chiefly  to  see  just 
what  it  is  that  her  neighbors  are  getting  when  they 
go  to  the  dispensary.  I  have  known  a  patient  to  come 
merely  because  he  was  alarmed  as  a  result  of  a  recent 
conversation  with  a  friend.  His  friend  had  been  hear- 
ing about  heart  trouble  and  had  mentioned  some 
symptoms  such  as  pain  about  the  heart  or  cold  ex- 
tremities or  dizziness.  Anyone  sick  or  well  on  hearing 
such  symptoms  may  easily  remember  that  he  has  had 
them  himself  not  long  ago,  or  may  even  begin  to  feel 
them  as  a  result  of  suggestion.  Straightway,  per- 
haps, he  will  betake  himself  to  the  dispensary,  com- 
plaining of  symptoms  which  never  would  have  been 
noticed  but  for  his  talk  with  the  friend. 

Or,  again,  the  patient  may  have  some  definite  or- 
ganic disease  or  some  obstinate  train  of  discomforts 
and  physical  inconveniences.  But  he  has  adapted 
himself  to  them  tolerably;  he  has  settled  down  to 
bear  or  forget  them  as  best  he  may.  He  may  know 
that  his  troubles  are  really  incurable  and  yet  not 
serious.  He  may  have  become  as  accustomed  to 
them  as  he  is  to  an  uncomfortable  lodging  or  to  a 
modest  income.  Yet,  as  a  result  of  some  temporary 


10  SOCIAL  WORK 

fatigue,  some  newspaper  paragraph,  some  fragment 
of  gossip  overheard,  there  may  arise  in  him  a  crisis 
of  alarm  and  worry  about  his  famiUar  discomforts 
or  inconveniences.  Thereupon  he  may  betake  him- 
self to  a  dispensary,  and  give  the  physician  an  ac- 
count which  may  be  very  difTicult  to  interpret,  be- 
cause the  physician  does  not  understand  the  train 
of  events  which  appear  acute  and  new  in  that  they 
have  led  the  patient  just  now,  rather  than  at  any 
earlier  time,  to  seek  advice.  After  nearly  twenty 
years'  experience  of  dispensary  work  I  should  say 
that  in  no  respect  can  a  social  worker  give  the  doctor 
more  welcome  help  than  by  discovering  now  and 
then  reasons  such  as  I  have  just  suggested  whereby 
the  patient  comes  to  the  dispensary  now  rather  than 
at  any  other  time,  and  at  a  season  not  really  con- 
nected in  any  special  way  with  the  nature  of  his 
disease. 

Perhaps  I  can  make  this  clearer  by  contrast  with 
its  opposite.  A  person  who  has  just  developed  a  scar- 
latinal rash,  who  has  just  coughed  and  raised  a 
considerable  quantity  of  blood,  who  has  just  lost  the 
power  to  move  half  of  his  body,  who  has  just  begun 
to  have  swelling  of  the  face,  naturally  consults  a  doc- 
tor at  once.  If  he  then  comes  to  a  dispensary  for 
treatment,  he  has  come  at  a  time  which  is  the  right 
time,  the  reasonable  time,  considering  the  nature  of 
his  malady.  Something  new  has  happened.  An  attack 
has  been  made  which  should  be  foiled  if  possible 
at  once.  The  clue  for  usefulness  on  the  part  of  the 


STANDING,  DUTIES,  EQUIPMENT     11 

doctor  is  thus  fairly  clear.  If,  on  the  other  hand,  a  per- 
son has  had  more  or  less  back-ache  all  his  Hfe,  and 
has  grown  used  to  gettmg  along  and  doing  his  work, 
even  enjoying  life  in  spite  of  it,  he  may  suddenly 
come  to  a  dispensary  for  that  back-ache  because  he 
has  seen  in  the  newspaper  the  wholly  false  state- 
ment that  pain  in  the  back  means  kidney  trouble. 
Yet  when  he  comes  to  the  dispensary  he  may  say 
nothing  whatever  about  his  having  seen  this  newspaper 
advertisement.  Indeed,  it  is  very  unlikely  that  he  will 
mention  this  at  all.  He  will  describe  his  back-ache 
as  something  which  demands  immediate  treatment, 
and  the  doctor  may  set  in  motion  extensive  and 
probably  useless  activities  of  investigation  or  treat- 
ment which  never  would  have  been  undertaken  had 
he  known  just  what  it  was  that  brought  the  patient 
to  the  dispensary  that  day  rather  than  months  ear- 
lier or  later. 

So  far  I  have  spoken  only  of  cases  in  which  the 
visitor's  studies  in  the  home  make  it  clear  that  the 
case  is  not  as  bad  or  not  as  manageable  as  it  might 
have  seemed  if  one  had  known  only  what  the  patient 
himself  could  reveal  in  the  dispensary.  But  occa- 
sionally on  reaching  the  patient's  home  the  visitor 
may  find  reason  to  believe  that  the  symptoms  are 
much  more  serious,  the  disease  much  more  urgent, 
than  could  have  been  realized  from  the  story  told 
and  the  facts  obtained  at  the  dispensary.  The  vis- 
itor may  find  in  the  home  conditions  of  disorganiza- 
tion, dirt,  disorder,  serious  malnutrition,  discourage- 


12  SOCIAL  WORK 

ment  on  the  part  of  other  members  of  the  family, 
arguing  a  much  more  serious  condition  of  the  patient 
than  one  would  have  realized  from  talking  with  him 
at  the  dispensary.  As  a  result  of  such  findings  the 
doctor,  who  must  spend  his  energies  for  the  patients 
who  need  him  most,  will  see  that  he  had  better  give 
more  time  and  more  effort  to  the  patient  than  he 
would  otherwise  have  thought  right. 

Still,  again,  the  visitor  may  find  that  the  symp- 
toms are  neither  more  serious  nor  less  serious  than 
he  would  have  supposed  from  the  dispensary  inter- 
view; yet  the  clinical  picture  is  different  from  the 
doctor's  because  the  patient  has  thrust  into  the  fore- 
ground of  the  clinical  picture  something  which  fur- 
ther knowledge  shows  to  be  really  unimportant, 
while  he  has  said  almost  nothing  of  some  other  fea- 
ture of  the  trouble  which  is  really  much  more  serious. 
For  example  how  much  does  the  patient  really  eat, 
how  does  he  do  his  work,  are  there  complaints  about 
him  from  his  "boss,"  has  he  always  had  the  cough 
which  he  has  only  just  now  begun  to  complain  of? 
Such  questions  can  be  better  answered  after  visits 
at  the  home  and  talks  with  the  whole  family. 

Clearly  the  supplementary  information  thus  se- 
cured by  the  social  worker  will  count  for  nothing 
unless  clearly  explained  to  the  doctor,  and  is  taken 
up  by  him  as  part  of  the  evidence  on  which  he  bases 
his  diagnosis  and  his  treatment.  It  is  absolutely  es- 
sential that  the  social  worker  should  not  merely  make 
her  visits  and  record  them  in  her  notebook,  but 


STANDING,  DUTIES,  EQUIPMENT     13 

should  incorporate  her  findings  in  the  medical  rec- 
ord and  deliver  them  not  formally  but  effectively 
to  the  doctor's  mind. 

Such  help  is  needed  because  she  can  often  learn 
far  more  in  the  quiet  of  an  interview  at  home  than 
would  be  possible  for  the  doctor  despite  all  his  medi- 
cal skill.  For  at  the  dispensary  he  questions  the 
patient  when  he  is  confused  and  forgetful,  alarmed, 
perhaps,  by  the  sights  and  sounds  of  the  clinic,  and 
so  very  unlikely  to  give  a  correct  and  well-balanced 
account. 

Nests  of  contagious  disease 

So  far  I  have  been  describing  the  work  of  the 
social  worker  as  a  process  of  finding  out  how  much 
ails  the  patient  and  what  his  symptoms  signify.  But 
it  is  also  a  part  of  the  social  worker's  duty  to  find  how 
much  disease  is  present  not  only  in  the  individual 
who  appears  in  the  clinic,  but  in  his  immediate  en- 
vironment, to  discover  nests,  foci  or  hotbeds  of  disease. 
In  the  case  of  a  disease  like  smallpox,  this  is  obvious. 
If  a  patient  presented  himself  at  a  dispensary  with 
the  pustules  of  smallpox  upon  his  body,  it  would  be 
criminal  negligence  on  the  part  of  the  physician  not 
to  set  on  foot  a  search  of  that  patient's  home,  his 
industrial  environment,  or,  in  the  case  of  a  child,  his 
school  environment,  for  evidence  that  others  have 
been  exposed  to  the  same  contagion  and  possibly 
already  infected.  This  sort  of  duty  cannot  be  aban- 
doned merely  because  there  is  no  health  officer  at 


14  SOCIAL  WORK 

hand.  It  is  a  cr^^ing  need  and  must  be  attended  to 
at  once. 

Now  in  a  minor  degree  this  is  true  of  many  other 
diseases  as  well  as  smallpox.  We  are  beginning  to 
realize  that  it  is  true  of  tuberculosis,  so  that  when 
one  case  of  advanced  and  therefore  contagious  tu- 
berculosis is  seen  at  the  dispensar\%  machinery 
should  automatically  and  invariably  be  set  in  motion 
to  search  out  possible  paths  of  contagion  from  that 
patient  to  others,  just  as  if  he  had  smallpox. 

This  principle  which  is  well  established  in  the 
case  of  dangerous  contagious  diseases  hke  smallpox 
and  diphtheria,  and  is  beginning  to  be  estabhshed  in 
relation  to  tuberculosis,  is  even  more  important  in 
dealing  "^dth  s3T)hihs.  Every  case  of  s^-phihs  means 
more  cases  of  s^^^hilis,  and  the  danger  of  still  more 
each  day  that  the  contagious  patient  is  at  large.  No 
physician  has  done  his  duty  unless,  after  seeing  a 
case  of  s^^Dhihs,  he  attempts,  through  a  social  worker 
or  othePA'ise,  to  get  knowledge  of  others  from  whom 
this  disease  has  been  acquired,  or  to  whom  it  may 
be  freshly  spread.  At  the  Massachusetts  General 
Hospital  each  patient  with  syphilis  is  asked  to  bring 
to  the  clinic  for  treatment  the  person  who  infected 
him.  The  method  sounds  impossible  but  in  fact  it 
works,  and  many  cases  are  thus  brought  under  treat- 
ment and  prevented  from  infecting  others. 

With  contagious  skin  diseases  such  as  scabies  or 
impetigo,  the  principle  is  obviously  the  same,  though 
the  dangers  of  disregarding  it  are  not  so  great.  With 


STANDING,  DUTIES,  EQUIPMENT     15 

typhoid  fever,  which  not  very  infrequently  shows 
itself  even  at  a  dispensary,  the  duty  of  the  social 
worker  is  not  so  much  to  search  for  other  persons 
through  whom  it  may  have  been  contracted  or  to 
whom  it  may  be  spread,  as  to  investigate  the  water- 
supply  and  the  milk-supply  of  the  patient  and  of 
others  in  his  environment.  One  case  of  typhoid  al- 
ways means  more  cases,  usually  more  cases  ac- 
quired, not  by  contact  with  one  another,  but  through 
their  share  in  a  contaminated  water-supply  or  milk- 
supply.  The  social  worker,  therefore,  should  know 
how  to  search  out  contaminated  water-suppHes,  or 
at  least  to  put  in  motion  such  machinery  of  public 
health  investigation  in  the  city  or  town  where  the 
case  arises  as  may  lead  to  good  detective  work  in  the 
attempt  to  track  down  the  source  of  the  trouble.  It 
has  been  well  said  that  every  case  of  typhoid  is  some 
one's  fault.  It  has  even  been  asserted  that  for  every 
case  of  t3TDhoid  some  one  should  be  punished.  Cer- 
tainly there  are  some  grounds  for  such  an  assertion. 

Hotbeds  of  industrial  disease 

Commoner  and  not  less  important  than  the  con- 
tagious diseases  that  I  have  just  mentioned  are  in- 
dustrial diseases,  or  diseases  aggravated  by  the  con- 
ditions of  industry.  A  physician  may  serve  for  many 
months  in  a  dispensary  without  seeing  a  case  of 
smallpox,  of  trichiniasis,  or  of  typhoid  fever,  or  feel- 
ing it  his  duty  to  set  in  motion  the  forces  that  I  have 
just  mentioned  for  rooting  out  the  sources  of  con- 


16  SOCIAL  WORK 

tagion  and  preventing  their  further  spread.  But  he 
cannot  serve  a  month  in  any  well-attended  dispen- 
sary without  seeing  cases  of  industrial  disease  in  the 
narrow  sense,  such  as  lead  poisoning,  or  of  independ- 
ent disease  aggravated  by  the  conditions  of  industry, 
such  as  the  functional  neuroses  of  cigar-makers  or  of 
telephone  operators.  With  such  diseases,  as  with  the 
infectious  and  contagious  diseases,  the  presence  of 
one  case  in  the  clinic  should  lead  straight  to  the  in- 
ference that  there  are  others  elsewhere,  out  of  sight 
but  no  less  important  from  the  point  of  view  of  pub- 
He  good.  This  conclusion  should  lead  in  turn  to  the 
search  through  a  social  worker  for  the  cases  of  disease 
which  do  not  present  themselves  to  any  physician, 
which  may  be  totally  unknown  even  to  the  patient 
himself,  yet  which  are  important  to  the  health  of  the 
nation. 

Difficult  though  this  field  of  industrial  disease  has 
shown  itself  to  be,  difficult  though  it  is  to  separate 
out  that  portion  of  the  patients'  complaints  which 
can  justly  be  referred  to  the  conditions  of  his  work, 
and  to  distinguish  it  from  the  portions  which  are  due 
to  the  way  he  lives,  to  his  inheritance,  to  his  habits 
or  to  diseases  like  tuberculosis  and  syphiUs  which 
may  have  been  acquired  without  any  connection 
with  his  work,  —  nevertheless  we  must  try  to  disen- 
tangle and  to  recognize  the  elements  in  this  knotty 
problem.  And  we  can  hardly  fail  to  see  that  the  social 
worker  is  an  essential  and  logical  assistant  in  the  pro- 
cesses of  investigation  which  we  must  carry  out.  If 


STANDING,  DUTIES,  EQUIPMENT     17 

we  can  ever  unravel  the  tangled  skein  of  causes  and 
effects  whereby  the  hours  of  work,  the  strain  of 
work,  the  patients'  heredity  and  his  home  condi- 
tions, all  combine  to  produce  the  symptoms  of  dis- 
ease, it  will  be  through  such  intimate,  prolonged, 
detailed  studies  as  the  social  worker  can  carry  out, 
especially  if  she  becomes  a  friend  of  the  family.  The 
doctor  in  his  hours  of  consultation  at  the  dispensary 
certainly  can  never  do  it.  The  official  agent  of  the 
Board  of  Health,  perhaps  feared,  certainly  not  a 
natural  confidant  for  the  family,  may  easily  miss 
the  truth  which  the  social  worker  unearths,  provided 
always  she  succeeds  in  differentiating  herself  alto- 
gether from  the  impersonal  and  professional  inves- 
tigator, and  gradually  becomes  in  the  mind  of  the 
family  and  in  truth  their  friend. 

I  said  above  that  the  social  worker  should  try  to 
find  out  what  disease,  how  much  disease,  and  why 
this  disease  is  present.  The  answers  to  these  three 
questions  cannot  be  kept  separate.  If  one  knows 
how  much  importance  to  attribute  to  a  given  symp- 
tom and  whether  it  is  as  bad  as  it  seems  or  worse 
than  it  seems  in  the  dispensary  interview,  one  may 
be  steered  straight  to  a  correct  diagnosis.  To  know 
how  much  disease  may  thus  mean  knowing  what  dis- 
ease is  present.  Furthermore,  the  understanding  of 
these  questions,  even  though  it  be  only  partial  and 
unsatisfactory,  leads  us  a  considerable  distance  to- 
wards understanding  why  the  disease  has  arisen.  The 
search  for  sources  for  contagion  is  an  example  of  a 


18  SOCIAL  WORK 

search  for  a  why  in  disease.  The  search  for  psychical 
factors  —  groundless  fears,  misleading  newspaper 
advertisements,  distracting  rumors  —  all  this  is  also 
a  search  for  the  cause  as  well  as  for  the  nature  of 
disease. 

The  social  worker's  investigations  into  the  cause  of 
disease  may  perhaps  be  still  further  exemplified.  I 
once  sent  a  social  worker  to  my  patient's  home  with 
the  request  that  she  try  to  find  out  what  I  had  failed 
to  find  out,  namely,  why  a  young  girl  could  not 
sleep.  Physical  examination  of  the  girl  had  revealed 
no  cause;  the  exploration  of  such  parts  of  her  mind 
as  she  would  reveal  to  me  had  thrown  no  hght  upon 
the  trouble.  I  was  at  a  loss  and  asked  for  help 
through  the  more  intimate  knowledge  of  the  patient 
sometimes  to  be  gained  through  a  social  worker's 
studies.  Such  a  search  might  easily  have  been  fruit- 
less —  it  often  has  been  fruitless  in  my  own  experi- 
ence. But  in  this  case  it  was  almost  comically  swift  in 
reaching  its  goal.  The  visitor  found  that  this  girl 
was  sleeping  ^vith  two  other  girls  of  about  her  own 
age,  in  a  bed  hardly  more  than  a  metre  wide.  It 
needed  only  that  she  should  acquire  a  separate  bed 
for  herself,  which  she  was  able  to  do  without  any 
fmancial  assistance.  She  then  regained  her  power  to 
sleep.  How  often  have  such  cases  been  treated  with 
drugs  or  perhaps  with  more  comphcated  physio- 
therapeutic or  psycho-therapeutic  procedures,  when 
some  simple  fact  like  the  size  of  the  bed,  the  tem- 
perature of  the  sleeping-room,  or  the  mental  activ- 


STANDING,  DUTIES,  EQUIPMENT     19 

ities  of  the  evening  immediately  preceding  bedtime, 
are  really  responsible  for  the  whole  trouble. 

Medical  outfit  of  the  social  worker 

In  order  to  carry  out  the  particular  procedures  of 
diagnosis  and  treatment  which  belong  within  the 
province  of  the  social  worker,  a  certain  amount  of 
medical  knowledge  is  needed.  Because  this  is  true,  it 
has  often  been  assumed  that  the  social  worker  must 
be  a  trained  nurse,  prepared  by  months  or  years  of 
experience  in  a  hospital.  But  experience  has  shown 
that  much  of  the  knowledge  possessed  by  nurses 
who  have  had  this  training  cannot  be  used  by  the 
home  visitor.  On  the  other  hand,  the  information 
which  the  social  worker  needs  is  often  quite  lacking 
even  in  well-trained  nurses.  Furthermore,  it  may  be 
said  with  truth  that  the  training  of  a  nurse,  as  we 
know  it  in  America  at  any  rate,  really  unfits  a 
woman  in  some  respects  for  the  work  of  a  social 
worker,  since  it  accustoms  her  to  habitual  obedience 
and  subordination.  These  habits  are  very  useful  in 
their  proper  place,  but  they  are  antagonistic  upon 
the  whole  to  the  temper  and  mental  activity  which 
is  important  in  the  social  worker.  I  mean  the  temper 
of  aggression  in  relation  to  disease,  and  the  men- 
tal attitude  of  the  teacher  and  leader  in  relation 
to  the  patient.  But  of  this  point  it  will  be  more  in 
place  to  speak  when  I  come  to  consider  the  functions 
of  the  social  worker  as  a  teacher. 

Let  us  return,  then,  to  the  question.  What  knowl- 


20  SOCIAL  WORK 

edge  should  the  social  worker  possess  in  order  to  do 
her  part  in  the  "team-work"  of  the  medical-social 
dispensary?  Her  knowledge  should  approximate 
that  of  the  pubhc  health  officer.  Like  him  she  should 
be,  above  all,  famihar  with  what  is  known  to  medical 
science  about  the  causes  of  disease.  This  is  of  great 
importance  because  it  is  especially  in  this  field  of 
medical  science  and  medical  ignorance  that  the 
pubhc,  the  patients  among  whom  the  social  worker 
will  work,  is  most  in  need  both  of  new  knowledge 
and  of  the  uprooting  of  old  error  and  superstition. 
Medical  science  knows  very  little  of  the  causes  of 
many  diseases.  But  our  patients,  especially  the  more 
ignorant  of  them,  are  very  glib  and  confident  in  their 
assertions  as  to  what  has  caused  the  particular  dis- 
ease from  which  they  just  now  suffer.  They  tell  us 
about  their  "torpid  livers,"  their  "congestive  chills," 
their  "ptomaine  poisonings"  and  the  like.  Their 
supposed  but  unreal  knowledge  is  extensive  and  de- 
tailed. Indeed,  so  stubborn  are  their  beUefs  upon 
such  matters  that  they  often  present  a  firm  wall  of 
resistance  which  must  be  broken  down  by  the  social 
worker  before  any  truth  upon  these  matters  can  be 
introduced  into  their  minds. 

The  social  worker,  then,  should  share  such  knowl- 
edge as  the  medical  profession  possesses  about  the 
causation  of  infectious  disease,  about  direct  personal 
contagion,  and  also  about  the  indirect  methods  by 
which  disease  is  conveyed  from  person  to  person 
through  insects  or  through  instruments  and  uten- 


STANDING,  DUTIES,  EQUIPMENT     21 

sils,  such  as  the  barber's  razor,  the  family  towel,  or 
the  pubhc  drinking-cup.  She  should  be  familiar  with 
the  small  body  of  knowledge  which  we  possess  upon 
the  transmission  of  disease  by  drinking-water,  by 
milk,  and  other  kinds  of  food.  She  should  appre- 
ciate our  still  smaller  body  of  knowledge  about  the 
relation  of  disease  to  climate,  to  weather,  and  to 
other  physical  agents  such  as  the  extreme  heat  and 
cold  produced  by  some  industrial  processes,  and  the 
action  of  X-rays. 

In  addition  to  this  definite  and  specific  knowledge 
of  causes,  she  should  know  the  generally  accepted 
views  of  the  medical  profession  on  the  subject  of 
bodily  resistance,  immunity,  inheritance,  the  dis- 
eases and  perversions  of  metabolism,  and  the  other 
non-bacterial  factors  in  the  production  of  disease. 
Above  all,  she  should  realize  the  multiplicity  of 
causes  which  science  more  and  more  clearly  recog- 
nizes in  their  single  result.  She  should  learn  both  by 
precept  and  by  experience  that  for  a  single  fact  such 
as  disease  or  health  there  are  always  many  causes, 
so  that  any  one  who  points  confidently  to  a  single 
cause,  such  as  cold,  fatigue,  bacteria,  or  worry  as  a 
sufficient  explanation  of  a  person's  disease,  is  almost 
certain  to  be  wrong.  Obviously,  this  truth  bears  a 
close  relation  to  what  is  to  be  said  on  the  "historic 
and  catastrophic  points  of  view."  Chapter  III. 

The  importance  of  teaching  the  social  worker  all 
that  is  known  about  the  transmission  and  causation 
of  disease  is  due  to  the  following  fact:  whatever  we 


22  SOCIAL  WORK 

succeed  in  accomplishing  in  our  efforts  at  preventive 
medicine,  whatever  we  do  to  nip  disease  in  the  bud 
or  to  check  the  spread  of  epidemics,  is  due  to  our 
knowledge  of  the  causes  of  disease.  The  instructions 
of  the  doctor  at  the  dispensary  can  accomplish  but 
little  in  this  field  when  compared  with  the  detailed 
teaching  of  the  social  worker  in  the  patient's  house, 
in  his  workshop,  in  the  schools  and  factories  where 
disease  is  spread  so  much  more  frequently  than  in 
the  dispensaries.  If  we  hope  to  show  people  how  they 
can  avoid  the  disasters  of  illness,  our  teaching  should 
be  given  in  the  very  place  where  these  disasters  most 
often  occur.  There  we  can  illustrate  and  demonstrate 
with  the  objects  in  sight  what  is  to  be  done  and  to 
be  avoided. 

It  is  for  this  reason  that  the  social  worker  is  above 
all  others  the  person  who  can  convey  life-saving  in- 
formation to  the  public  in  an  effective  way.  A  con- 
siderable amount  of  this  precious  knowledge  is  now 
possessed  by  the  medical  profession;  but  it  is  shut 
away  useless,  unavailable,  in  medical  libraries  and 
in  doctors'  minds.  The  social  worker  can  fight  disease 
by  spreading  the  contagion  of  medical  truth.  She 
can  multiply  the  foci  from  which  triith  can  spread 
still  more  after  she  is  gone,  just  as  disease  is  redis- 
tributed again  and  again  from  new  nests  of  infection. 

The  prognosis  of  disease,  like  its  causation,  is  a  sub- 
ject on  which  the  social  worker  should  know  almost  as 
much  as  the  doctor.  This  is  possible  because  medical 
knowledge  on  this  subject  is  still  so  very  hmited.  For 


STANDING,  DUTIES,  EQUIPMENT     23 

the  purposes  of  one  who  has  to  combat  the  poverty, 
sorrow,  idleness,  and  corroding  fears  which  disease 
produces,  knowledge  of  prognosis  is  a  most  useful 
tool.  For  example:  if  one  is  to  make  plans  for  the 
care  of  a  group  of  children  during  their  mother's  ill- 
ness, one  must  have  some  idea  how  long  that  illness 
is  going  to  last.  If  it  affects  the  bread-winner  of  the 
family,  how  long  will  he  or  she  be  disabled,  and  how 
completely;  what  are  the  hopes  of  ultimate  and 
complete  recovery;  will  chronic  invalidism  follow; 
is  it  worth  while  in  this  particular  disease  to  spend  a 
great  deal  of  money  and  time  in  trying  to  achieve  a 
complete  cure,  or  is  cure  so  improbable  and  at  best 
so  incomplete  that  our  resources  can  be  expended 
more  wisely  in  other  directions? 

A  knowledge  of  prognosis  will  help  the  home  visi- 
tor greatly  in  the  solution  of  such  problems.  But  it 
must  be  added  that  such  knowledge  as  she  already 
possesses  about  the  prognosis  of  a  disease,  such  as 
tuberculosis  or  heart  trouble  or  kidney  trouble,  must 
always  be  supplemented  by  all  the  information  that 
she  can  gain  from  the  doctor  as  to  the  present  prog- 
nosis in  the  case  of  the  particular  patient  with  whom 
the  social  worker  has  to  deal.  For  the  general  prog- 
nosis of  a  disease  is  greatly  modified  by  the  particu- 
lar circumstances  in  each  individual  case. 

Physicians  are  not  at  all  eager  to  impart  their 
knowledge  about  prognosis,  because  this  knowledge 
is  so  limited  and  so  faulty.  No  scientific  man  likes  to 
make  definite  statements  upon  so  indefinite  and  hazy 


24  SOCIAL  WORK 

a  matter  as  prognosis.  Nevertheless,  it  is  essential 
for  the  patient's  good  that  the  doctor  should  be 
asked  to  give  her  as  clear  and  definite  a  statement 
as  is  possible  for  him  to  make  with  the  facts  that 
he  possesses.  For  it  is  only  upon  the  basis  of  such  a 
statement  that  an  intelhgent  plan  of  social  treat- 
ment can  be  constructed. 

Besides  acquiring  all  that  she  can  learn  of  the 
causes  and  prognosis  of  disease,  the  social  worker 
should  be  famihar  with  the  symptoms  of  the  more 
important  and  common  types  of  disease.  There  are 
now  several  books  wTitten  particularly  with  the  ob- 
ject of  conveying  to  social  workers  and  others  such 
knowledge  as  I  have  referred  to,  yet  without  any 
pretence  of  equipping  the  person  either  for  nursing 
or  for  the  practice  of  medicine.  I  will  mention  here  a 
book  by  Dr.  Roger  I.  Lee,  Professor  of  Hygiene  in 
Harvard  University,  "Health  and  Disease:  Their 
Determining  Factors"  (Little,  Brown  &  Co.,  Bos- 
ton, 1917),  and  my  own  book,  "The  Layman's 
Handbook  of  Medicine"  (Houghton  Mifflin  Co., 
Boston,  1916). 

In  order  to  understand  such  books,  and  to  arrange 
her  knowledge  of  disease  in  such  form  that  it  may  be 
easily  handled,  the  social  worker  must  have  a  shght 
knowledge  of  anatomy  and  physiology,  so  that  she 
can  arrange  the  symptoms  of  disease  in  connection 
with  the  different  systems  of  organs:  circulatory, 
digestive,  respiratory,  urinary,  nervous,  and  loco- 
motive. 


STANDING,  DUTIES,  EQUIPMENT     25 

Finally,  the  social  worker  must  know  the  principles 
of  hygiene,  in  order  that  she  may  effectively  combat 
medical  quackery  and  the  prevalent  medical  super- 
stitions of  the  people.  That  portion  of  hygiene  which 
is  both  securely  founded  upon  scientific  evidence 
and  useful  in  the  preservation  of  health,  makes  up 
only  a  very  small  body  of  knowledge,  so  that  it  can 
be  easily  mastered  by  any  inteUigent  person.  Our 
knowledge  upon  such  matters  as  diet,  exercise,  bath- 
ing, sleep,  ventilation,  when  such  knowledge  is  both 
scientific  and  practically  useful,  could  be  written 
upon  a  very  few  pages.  It  consists  largely  of  nega- 
tives which  contradict  the  current  superstitions. 

In  my  own  work  in  this  field  I  have  found  it  es- 
sential that  there  should  be  no  mystery  and  con- 
ceahnent,  no  obscurantism  and  mediaeval  Latin  in 
the  methods  of  treatment  which  the  social  worker 
explains  or  carries  out  under  the  doctor's  direc- 
tions. She  must  be  able  to  deal  with  the  patients 
frankly,  openly,  without  concealment  or  prevarica- 
tion. Otherwise  she  will  not  have  moral  force  enough 
behind  her  statements  to  bring  them  home  to  the  pa- 
tient so  as  to  secure  any  reform  in  his  hygienic  hab- 
its. Such  reforms  are  difficult  enough  in  any  case. 
They  are  usually  impossible  unless  they  can  be  ini- 
tiated by  one  rendered  eloquent  and  convincing  by 
the  consciousness  that  she  leans  upon  the  truth  and 
has  nothing  to  conceal.  If  she  has  mental  resei'va- 
tions,  if  she  is  trying  to  protect  the  authority  of  the 
physician  in  a  statement  which  she  does  not  believe 


26  SOCIAL  WORK 

to  be  wholly  true,  the  force  of  her  appeal  will  be  so 
weakened  that  it  will  probably  be  ineffective. 

Technical  methods 

There  are  some  technical  processes  of  diagnosis 
and  treatment  which  are  usually  carried  out  by  the 
visiting  nurse,  but  which  may  well  be  performed 
after  a  brief  training  by  the  social  worker  who  is  not 
a  nurse.  Among  these  are : 

(1)  The  accurate  reading  of  the  patient's  temper- 
ature, pulse,  and  respiration,  which  she  must  often 
teach  the  patient  to  do  for  himself  and  to  record 
accurately  and  clearly.  This  is  of  especial  importance 
in  tuberculosis,  for  in  suspected  cases  of  this  disease 
one  often  needs  daily  measurements  of  the  tempera- 
ture as  an  aid  in  determining  the  diagnosis  or  in  es- 
timating the  severity  of  the  case  and  the  fitness  of 
the  patient  for  work. 

(2)  The  arrangement  of  a  window  tent  or  some 
other  device  for  insuring  the  maximum  of  fresh  air 
for  the  tuberculous  patient  both  day  and  night.  This 
device  is  also  useful  in  pneumonia,  t^^hoid  fever, 
and  other  diseases,  in  case  they  are  to  be  cared  for 
at  home  and  not  in  a  hospital. 

(3)  The  application  of  simple  dressings  to  wounds, 
abscesses,  and  conmion  skin  diseases  such  as  eczema, 
and  impetigo. 

(4)  The  care  of  the  skin  in  bedridden  patients.  Our 
primary  object  here  is  the  prevention  of  bedsores, 
those  ulcerations  which  occur  in  very  emaciated 


STANDING,  DUTIES,  EQUIPMENT     27 

patients  at  the  points  where  their  weight  presses  a 
bone  against  the  bedclothes. 

(5)  The  simpler  procedures  for  the  preparation  of 
milk  for  sick  children  and  of  other  foods  commonly 
advised  for  patients  who  are  confined  to  bed. 

(6)  The  methods  of  emptying  the  lower  bowel  by 
means  of  an  enema. 

Into  the  details  of  these  procedures  this  is  not  the 
place  to  enter,  but  I  wish  specially  to  assert  that 
all  of  them  may  be  learned  within  a  few  weeks  by 
persons  who  have  not  studied  medicine  or  had  the 
full  course  for  the  training  of  a  nurse.  Any  one  who 
possesses  these  simple  bits  of  skill  can  do  all  that  is 
necessary  for  the  physical  care  of  the  sick  poor  in 
their  homes,  unless  continuous  attendance  upon  the 
patient  is  necessary.  Such  attendance  is  not  within 
the  province  of  the  social  worker.  But  in  the  tech- 
nical procedures  just  described  it  is  all  the  more  im- 
portant that  she  be  expert,  because  such  skill  makes 
her  a  welcome  visitor  and  a  trusted  adviser  outside 
the  field  of  medicine.  Because  she  has  given  relief 
by  dressing  a  wound,  curing  a  skin  disease,  or  ap- 
plying a  poultice,  she  will  be  listened  to  with  liking 
and  with  confidence  when,  later,  she  comes  to  give 
advice  in  economic,  educational,  or  moral  difficulties. 


CHAPTER  II 

HISTORY-TAKING  BY  THE  SOCIAL  ASSISTANT 

History-taking  concerns  the  social  assistant  es- 
pecially because  history-taking  is  one  of  the  things 
one  does,  if  one  is  wise,  in  any  matter  in  which  one 
is  trying  to  help  a  human  being.  Even  if  you  were 
concerned  to  help  not  a  stranger,  but  a  member  of 
your  own  family,  still  you  would  need  a  story  or 
history  of  the  person's  hfe  whether  you  wrote  it 
down  or  not. 

History  and  catastrophe 

In  our  attempts  to  be  of  use  to  people  in  their 
misfortunes,  there  are  two  very  common  and  quite 
opposite  points  of  view  (roughly  the  right  and  the 
wrong),  which  I  call  {a)  the  "historic"  and  (b)  the 
"catastrophic,"  the  accidental,  or  the  emergency 
point  of  view. 

Confronted  with  people's  troubles,  whether  phy- 
sical or  mental  or  spiritual,  we  are  tempted,  and 
above  all  they  are  tempted  to  regard  the  sickness,  the 
poverty,  or  the  sorrow  in  the  hght  of  an  emergency, 
an  accident,  and  therefore  as  something  to  be  treated 
at  once  and  by  means  which  have  Uttle  to  do  with 
the  past  and  the  future.  On  the  other  hand,  the 
standpoint  of  science  and  philosophy,  and  of  any  one 
who  has  labored  long  in  the  field  of  social  work  with 


HISTORY-TAKING  29 

or  without  science  or  philosophy,  is  the  point  of  view 
of  history.  This  is  the  habit  of  mind  which  makes 
us  beheve  that  a  supposed  "accident"  belongs  in  a 
long  sequence,  a  long  chain  of  events,  so  that  it  is 
impossible  to  understand  or  to  help  it  without  knowl- 
edge, as  extensive  as  our  time  and  our  wisdom  will 
allow,  of  that  whole  chain. 

Consider  a  few  examples  which  contrast  these  two 
points  of  view.  When  a  boy  is  brought  into  court  for 
steahng,  it  is  almost  always  his  attempt,  and  the 
attempt  of  those  who  defend  him,  to  show  that  such 
a  thing  has  never  happened  in  his  life  before;  he 
"just  happened  to  steal."  But  as  we  inquire  more 
closely  into  the  facts,  we  almost  always  fmd  that 
this  is  a  fundamentally  untrue  statement  of  the 
case.  For  the  offence  which  brought  him  into  court 
is  almost  never  the  first  offence.  He  has  always  stolen 
before.  On  the  present  occasion  he  was  a  member  of 
a  boy's  gang;  it  was  not  in  the  least  accidental  that 
he  got  into  that  group  of  boys.  As  we  search  back  in 
his  history,  and  perhaps  into  his  father's  history,  we 
fmd  reasons  why  he  is  what  he  is  now.  Again,  we  are 
trying  to  help  some  wayward  girl  who  has  taken  an 
immoral  step.  We  are  told  what  a  wholly  unforesee- 
able accident  it  was  that  got  her  into  her  trouble. 
But  if  we  can  get  a  good  picture  of  her  past,  we  fmd 
that  we  could  have  traced  the  tendency  to  weakness 
of  this  kind  from  the  time  she  was  born. 

So  it  is  in  medical  matters.  Emergencies  are  rare. 
1  remember  being  called  out  of  a  sound  sleep  one 


30  SOCIAL  WORK 

night  to  go  "as  quickly  as  possible"  to  see  a  man 
who  had  discovered  a  lump  upon  his  breast  bone. 
He  was  quite  sure  that  the  sweUing  had  appeared 
since  the  time  when  he  went  to  bed.  It  was  then  one 
o'clock  in  the  morning,  and  he  had  gone  to  bed  at 
eleven.  Well,  I  found  a  slight  bony  irregularity  in  his 
breast  bone  which  doubtless  had  been  there  about 
forty-five  years,  as  he  was  forty-six  years  old.  He 
did  not  pretend  that  it  hurt  him,  and  did  not  under- 
take to  show  that  he  was  ill  in  any  other  way.  But 
this  lump  had  come  and  naturally  he  wanted  help 
at  once. 

The  great  importance  of  the  contrast  between  the 
historic  and  the  catastrophic  points  of  view  is,  in  the 
first  place,  that  one  way  is  on  the  whole  right  and 
the  other  on  the  whole  wrong;  but  still  more,  that 
the  patients  whom  we  are  going  to  deal  with,  and  all 
the  unfortunate  or  needy  people  whom  the  social 
assistant  tries  to  help,  are  very  fond  of  the  wrong 
point  of  view  and  hang  to  it  extraordinarily.  It  is  the 
natural  first  impression  of  any  untrained  person  that 
his  troubles  "simply  happen"  without  any  explana- 
tion that  he  knows.  So  that  we  have  to  start  at  once 
to  tear  down  a  structure  of  innocent  and  lifelong  be- 
lief on  the  part  of  the  patient,  that  troubles  come 
suddenly  and  by  accident.  We  have  to  disillusion 
him,  a  process  which  naturally  he  does  not  take  to 
particularly  pleasantly. 

Our  task  in  a  dispensary  is  the  same.  The  patient 
almost  always  starts  with  the  catastrophic  point  of 


HISTORY-TAKING  31 

view,  and  can  only  be  very  gradually  engineered 
into  the  other.  And  yet  our  work  in  relation  to  pub- 
He  health  is  largely  to  be  summed  up  as  finding  out 
how,  —  that  is  by  what  history,  through  what  chain 
of  events,  people  come  to  be  sick.  Repetition  and 
extension  of  disease  can  be  checked  only  in  case  we 
succeed  in  finding  such  clues.  Hence  our  labors  to 
change  people's  point  of  view  in  this  particular  re- 
spect are  as  worth  while  as  anything  we  can  do,  and 
we  must  not  be  discouraged  by  the  fact  that,  week 
after  week  and  year  after  year,  we  come  up  against  the 
same  difiiculties,  the  same  conviction,  that  troubles 
"just  come"  and  have  no  cause. 

I  have  said  that  the  historic  prejudice  is  essentially 
right  and  the  catastrophic  prejudice  essentially 
wrong.  Of  course,  there  are  exceptions.  A  man  may 
be  run  over  in  the  street  for  reasons  that  we  cannot 
discover  to  be  connected  in  any  possible  way  with 
his  previous  history;  a  man  gets  a  burn,  gets  a 
broken  leg,  is  hit  by  a  missile  in  an  air  raid  over 
London  or  Paris,  in  ways  that  are  essentially  ca- 
tastrophic. And  yet  even  in  the  field  of  accidents, 
industrial  accidents  for  instance,  the  more  we  study, 
the  more  we  find  that  injuries  are  not  wholly  acci- 
dental. The  whole  of  science  is  the  attempt  to  prove 
that  nothing  is  an  accident,  that  everything  comes 
out  of  previous  causes.  The  percentage  of  accident 
in  the  so-called  "accidental"  injuries  decreases  as 
we  study  industrial  accidents,  (a)  They  happen  at 
certain  hours  of  the  day  more  than  at  other  hours  of 


32  SOCIAL  WORK 

the  day:  if  they  were  really  accidental  this  would 
not  be  so.  (b)  They  happen  on  certain  days  of  the 
week,  especially  Mondays,  for  obvious  reasons,  (c) 
They  happen  especially  to  greenhorns,  to  the  new- 
comers, who  have  not  learned  how  to  avoid  them. 
One  of  the  expenses  incidental  to  hiring  new  help 
is  the  expense  of  accidents.  Thus  these  events  turn 
out  to  have  a  good  deal  of  law  and  reason,  a  good 
deal  in  the  history  of  the  individual  (alcohohsm?), 
and  the  nature  of  the  industrial  process  (speeding 
up?)  which  helps  to  explain  them.  By  eliminating 
such  causative  factors,  we  may  prevent  some  acci- 
dents. 

The  remedies  that  we  apply  fit  the  type  of  trouble; 
in  so  far  as  the  trouble  is  accidental  or  catastrophic, 
the  remedy  is  mechanical;  in  so  far  as  the  thing  is 
historical  and  continuous,  the  remedy  cannot  be 
mechanical.  When  a  man  breaks  his  leg  we  put  on  a 
splint;  that  is  mechanical.  But  if  he  is  in  a  low  state 
of  health  and  the  fracture  won't  unite,  we  have 
to  do  something  non-mechanical,  physiological,  psy- 
chological. We  may  have  to  get  him  into  a  different 
state  of  nutrition  or  even  into  a  better  state  of  mind 
before  his  tissues  will  heal. 

Our  job,  then,  in  taking  histories  —  that  is,  in  find- 
ing out  how  things  happen  that  lead  up  to  disease 
or  misfortune  —  should  begin  by  writing  down  the 
thing  for  which  the  patient  comes  —  headache,  cough, 
emaciation,  poverty,  desertion,  unemployment.  This 
is  the  "presenting  symptom";  it  should  always  be 


HISTORY-TAKING  33 

the  first  thing  written  down  in  our  history,  not  in 
terms  of  medical  diagnosis  such  as  asthma  or  ane- 
mia, but  in  the  form  of  a  complaint.  Our  attempt 
is  first  to  put  that  down,  to  get  a  starting-point, 
and  then  to  weave  that  into  a  chain  of  evidence 
which  we  call  a  history.  That  history  makes  it  pos- 
sible to  make  a  diagnosis  and  to  plan  treatment. 

The  network  of  events 

But  the  particular  event,  the  particular  complaint 
for  which  the  patient  comes  to  us,  is  woven  not 
merely  into  one  chain  of  evidence,  but  into  several. 
Let  us  carry  out  the  metaphor  of  the  chain.  We 
must  imagine  many  chains  woven  into  one  another 
like  the  chain-armor  of  the  mediaeval  knight.  Each 
link  is  a  fact.  But  many  chains  of  facts  are  inter- 
woven in  the  history  of  one  single  patient.  First 
there  is  the  chain  of  medical  evidence,  the  hnks  (or 
symptoms)  leading  up  to  a  diagnosis;  second,  the 
chain  of  social  evidence,  which  we  try  to  classify  on 
our  social  history  card.  Third,  we  must  trace  the 
links  in  the  chain  of  relationship  with  other  people, 
other  members  of  the  family,  with  friends  and  fellow 
workers  or  schoohnates.  Finally,  the  chain  of  hered- 
ity, of  which  we  cannot  make  much  at  present  ex- 
cept in  relation  to  tuberculosis  and  mental  disease 
or  mental  deficiency.  But  these  studies  of  heredity 
in  its  bearing  on  character  are  going  to  be  more  im- 
portant as  the  science  of  social  work  develops. 

Our  first  attempt,  then,  after  determining  the 


34  SOCIAL  WORK 

"presenting  symptom,"  is  to  find  out  by  a  series  of 
questions  how  this  symptom  is  linked  up  into  a  tis- 
sue composed  of  many  chains  of  facts.  Our  next  task 
which  is  usually  difficult,  and  frequently  impossible, 
is  to  find  out  why  this  great  tissue  of  evidence  issues 
just  now  in  one  particular  "presenting  symptom." 
Why  did  the  patient  come  to  us  to-day?  This  ques- 
tion is  often  impossible  to  answer  because  the  pa- 
tient does  not  know,  though  he  may  think  he  knows. 
Nevertheless,  the  social  worker  must  try  to  find  out. 
Often  it  is  not  until  we  have  known  and  Uked  a  person 
for  days  or  weeks  that  we  find  out  why  he  came  to  us 
at  this  particular  time.  Yet  the  answer  to  this  ques- 
tion may  be  the  most  important  thing  that  we  can 
find  out.  For  two  reasons  it  is  important;  first,  be- 
cause it  furnishes  the  clue  to  all  our  later  investiga- 
tion and  assistance  in  this  case;  secondly,  because  it 
may  show  that  the  individual's  complaints  are  not 
of  any  significance  at  all. 

I  can  illustrate  this  by  a  case  studied  at  the  Mas- 
sachusetts General  Hospital  in  Boston.  We  looked 
up  a  series  of  patients  at  their  homes  in  order  to  find 
out  if  we  had  really  been  of  any  service.  The  cases 
were  not  selected,  but  were  taken  from  our  files  in 
numerical  order.  Among  others  we  visited  a  lady 
whose  malady  had  been  diagnosed  as  "sacro-ihac 
strain."  She  had  been  given  a  prescription  for  a  belt. 
We  wanted  to  find  out  whether  she  had  ever  bought 
the  belt  and  whether  it  had  helped  her.  After  some 
difficulty  the  visitor  finally  got  the  following  details: 


HISTORY-TAKING  35 

The  lady  had  come  from  a  city  twenty  miles  distant 
from  Boston.  She  had  taken  an  early  morning  train, 
and  could  not  get  back  to  her  home  the  same  night. 
Hence  she  could  not  soon  make  another  trip  hke 
that.  She  came  to  have  her  eyes  examined.  Now  it 
happened  that  we  had  no  eye  clinic  at  the  hospital 
at  that  time.  But  the  lady  had  heard  a  great  deal 
about  the  hospital  and  its  eflficiency.  She  was  deter- 
mined not  to  go  home  without  having  got  something 
out  of  the  hospital.  So  when  she  was  told  at  the 
Admission  Desk  that  she  could  get  no  treatment  for 
diseases  of  the  eye,  she  wandered  into  the  medical 
clinic,  trying  to  remember  or  imagine  some  symp- 
toms for  the  relief  of  which  she  could  be  admitted  to 
the  clinic.  Finally  she  managed  to  get  out  some  sort 
of  a  story  about  a  pain  in  her  back;  she  was  re- 
ferred to  the  orthopedic  division;  there  a  diagnosis 
of  sacro-iliac  disease  was  made  and  a  belt  was  ad- 
vised. When  she  got  home,  of  course,  she  laughed  at 
the  idea  of  buying  a  costly  belt. 

Now,  if  we  could  have  found  out  in  the  beginning 
why  she  came  to  the  hospital,  we  might  have  saved 
a  good  deal  of  bother  for  a  good  many  people.  It  is 
astonishing  how  many  patients  turn  out  to  have  as 
little  reason  for  coming  now  as  this  lady  did.  One 
of  the  things  that  shows  the  arbitrariness  of  choice 
in  selecting  a  time  for  visiting  the  hospital,  is  the 
striking  diminution  in  the  number  of  patients  in  the 
week  before  Christmas.  That  suggests  that  there 
are  many  postponable  visits.  Or  again,  patients  may 


36  SOCIAL  WORK 

come  merely  because  somebody  else  from  the  same 

neighborhood  is  coming. 

Listening  and  questioning 

As  the  histor^^-taker  traces  out  the  s^TQptoms  of 
the  patient's  illness  after  finding  an  answer  to  this 
first  question,  Why  to-day  ?  two  opposite  habits  of 
mind  must  be  employed,  one  passive,  the  other  ac- 
tive. We  must  be  sure  that  the  patient  shall  feel  that 
he  has  had  a  good  Ustener,  that  his  troubles  have 
really  been  appreciated.  But  if  we  are  constantly 
putting  in  questions,  as  we  certainly  must  later,  the 
patient  does  not  feel  that  he  has  been  hstened  to. 
We  desire  first  of  all  to  get  his  owti  story  in  his  own 
words,  passively.  We  may  not  necessarily  write  down 
a  single  word  of  it.  But  I  have  found  that  the  pa- 
tient's o\\Ti  way  of  expressing  the  nature  of  his 
troubles  is  often  important  and  characteristic.  It 
helps  to  prevent  our  histories  from  looking  too  much 
alike,  wliich  is  their  commonest  fault.  Hence  w-e 
should  get  into  them  somewhere  a  phrase  or  sev- 
eral phrases  reported  passively  in  the  patient's  o\^ti 
words;  if  possible  a  phrase  in  which  he  describes 
his  "presenting  s^miptom,"  the  thing  of  which  he 
chiefly  complains. 

But  the  second  stage  in  the  process  of  taking  a  pa- 
tient's history"  is  the  most  important.  In  this  part  we 
should  be  active,  not  passive.  We  must  attack  our 
task  with  a  tool  in  our  hand,  a  mental  tool  fitted  to 
rake  out  of  the  mass  of  confused  ideas  in  his  mind 


HISTORY-TAKING  37 

certain  significant  facts.  That  rake  is  a  logical  sched- 
ule of  questions  which  you  use  upon  him  actively, 
not  passively,  and  by  using  which  you  get  answers 
either  negative  or  positive.  Whenever  you  think 
well,  you  think  with  a  schedule  of  that  kind  in  your 
mind.  If  you  pack  a  trunk  well,  you  pack  it  using  a 
list,  a  schedule  of  the  things  that  ought  to  go  into 
that  trunk.  Our  printed  social  face-card  helps  us  to 
think  and  question  with  a  schedule  before  us,  to 
think  in  an  orderly  way,  without  forgetting  our 
items,  and  thus  to  select  what  we  need  out  of  the 
mass  of  disorderly  facts  in  the  patient's  memory. 

In  the  second  phase  of  history-taking,  then,  which 
begins  after  we  have  listened  appreciatively  but 
quietly  to  the  patient's  own  version  —  usually  ca- 
tastrophic and  full  of  fanciful  theories  —  we  lead 
him  by  questions  (but  not  by  "leading  questions") 
along  the  paths  which  will  open  up  a  full  view  of  the 
trouble,  medical  or  social,  which  has  been  suggested 
to  us  by  the  patient's  first  statements.  Suppose,  for 
instance,  one  happened  to  know  of  an  extraordina- 
rily rare  but  curable  disease,  one  sjmiptom  of  which 
the  patient  had  mentioned,  "My  hair  comes  out  by 
handfuls."  One  would  go  on  to  ask,  "Do  you  feel 
warmer  or  colder  than  usual  this  winter?"  Then, 
"The  expression  of  your  face  is  not  notably  changed, 
is  it,  so  that  your  friends  comment  on  it?  "  "  Is  your 
skin  drier  or  moister  than  usual?"  "Does  your 
tongue  bother  you  in  any  way?  "  "Is  your  mind  more 
or  less  active  than  usual?"  Thus  one  would  confirm 


38  SOCIAL  WORK 

or  refute  the  suggestion  of  the  disease  called  myxoe- 
dema,  a  suggestion  which  was  given  to  us  by  the 
patient's  first  complaint  —  rapid  loss  of  hair.  Given 
one  sjonptom  in  a  known  group,  one  can  trace  out 
the  others  as  the  anatomist  who  finds  a  single  fish- 
bone may  be  able  to  reconstruct  imaginatively  the 
whole  fish. 

I  said  just  now  that  we  must  not  ask  "leading 
questions."  If  we  do,  we  can  make  a  patient  of  a  very 
suggestible  t^^e  of  mind  say  anything.  If  you  ask 
him  whether  he  has  any  symptom  whatsoever  he 
may  obligingly  say  "yes."  The  way  to  avoid  this  is 
to  put  our  questions  in  the  negative:  "You  have  no 
headache  at  all,  have  you?"  "You  do  not  cough?" 
"You  never  spit  blood?"  By  these  negatives  we  can 
get  at  the  positive  symptoms  if  they  are  present. 

Schedules  of  questions  to  be  used  in  history-taking 
may  be  medical  or  social.  Some  of  the  social  ques- 
tion-lists are  suggested  in  later  chapters  of  this  book. 
A  masterly  account  of  social  questioning  is  contained 
in  Miss  Mary  E.  Richmond's  "Social  Diagnosis" 
(published  by  the  Survey  Associates,  New  York, 
1917). 

I  wish  now  to  illustrate  the  methods  to  be  used  by 
social  workers  in  questioning  patients  about  their 
s^TQptoms  so  as  to  assist  the  doctor  in  his  diagnosis, 
r-  Pain:  How  long?  For  a  day,  a  month,  a  year,  six 
years?  Very  chronic  pains  are  seldom  serious  but 
seldom  curable.  Headache  that  has  lasted  years 
either  has  no  cause  known  to  medical  science,  or  else 


HISTORY-TAKING  39 

it  means  neurasthenia.  In  either  event  it  is  apt  to  be 
stubborn.  A  headache  that  has  lasted  only  a  day, 
and  did  not  occur  before,  cannot  possibly  be  due  to 
migraine.  This  suggests  how  the  length  of  time  that 
a  pain  has  lasted  is  very  important  in  diagnosis. 
The  patient  will  often  say,  "I  have  always  had  it"; 
but  to  this  we  should  oppose  a  pretty  strong  cross- 
examination.  The  patient  usually  means  that  he  has 
had  it  off  and  on  throughout  an  indefinite  period. 
We  ask  him  then,  "When  did  you  first  have  it?" 
and  then,  "How  much  of  the  time  —  half  the  time, 
a  quarter  of  the  time,  for  one  day  a  week  or  one  day 
a  month?" 

Pain:  Where?  Patients  rarely  come  to  a  doctor 
for  a  single  point.  But  pain  in  several  points  is  never 
as  significant  as  pain  in  one  point.  One  cannot  learn 
much  from  scattered  pains  in  relation  to  what  ails 
the  patient  and  what  to  do  for  him. 

Pain: How  bad?  That  is  a  very  difficult  question 
to  get  the  answer  to.  There  is  no  thermometer  or 
measure  for  pain.  I  suppose  every  doctor  has  wished 
many  times  that  he  had  one.  But  there  are  certain 
rough  measures  which  are  of  some  use  in  judging 
how  bad  a  pain  is.  (1.)  We  ask,  "Does  it  compel  you 
to  lose  sleep?"  Some  headaches  may  be  pretty  severe 
and  yet  a  person  sleep  despite  the  pain.  It  may  link 
itself  up  with  a  dulling  of  consciousness  leading  to 
sleep.  But  most  pains  and  even  most  headaches  that 
do  not  keep  a  person  awake  are  not  as  bad  as  those 
that  do.  (2.)  We  ask,  "Does  it  prevent  work?"  Any 


40  SOCIAL  WORK 

one  can  see  all  sorts  of  limitations  to  the  use  of  that 
criterion.  A  man  with  a  rugged  type  of  mind  will 
work  with  a  pain  that  another  weaker  man  will  give 
up  to.  Yet  the  question  does  bring  out  evidence  of 
some  value. 

(3.)  Another  criterion,  more  subtle  and  not  quite  so 
useful,  is  this,  "Do  you  feel  the  pain  more  when  you 
are  quiet  or  when  you  are  moving  about?"  The  pains 
due  to  organic  diseases  are  generally  worse  when  one 
moves;  while  the  functional  type  of  pains  are  apt  to 
be  better  when  one  moves  about.  One  forgets  it. 
Quite  often  patients  are  very  lucid  and  candid  about 
this. 

Pain:  How  aggravated?  How  relieved?  (a)  A  pain 
may  be  aggravated  by  position  —  for  example,  when 
the  patient  is  on  his  feet  —  or  worse  when  he  is  lying 
down  —  a  headache,  for  instance.  Most  abdominal 
pains  are  worse  when  the  patient  is  on  his  feet. 
(b)  A  pain  may  be  aggravated  by  motion.  Most  of 
the  surgical  injuries,  sprains,  strains,  tears  of  muscle 
or  ligament,  and  fractures  of  bones  are  naturally 
made  worse  by  motion.  Pain  may  be  aggravated  by 
certain  particular  motions,  as  is  the  case  with  some 
of  the  innumerable  pains  in  the  back.  Lumbago  is  a 
pain  characteristically  described  as  one  that  comes 
when  the  patient  tries  to  lace  his  boots.  Especially 
when  he  tries  to  get  up  from  that  position,  the  pain 
is  intolerable.  Pains  in  the  chest  are  often  worse  on 
deep  breathing  —  pleuritic  pains,  for  example.  But 
other  thoracic  pains  may  also  be  made  worse  by  deep 


HISTORY-TAKING  41 

breathing,  (c)  Pain  may  be  aggravated  by  the  taking 
of  food,  or  by  movements  of  the  bowels. 

Pain  may  also  be  relieved  in  any  of  these  ways. 
The  most  important  thing  that  one  can  know  about 
a  stomach  pain  is  that  it  is  reheved  by  food.  The 
majority  of  all  stomach  pains  are  aggravated  by 
food.  Pains  are  also  relieved  by  heat  or  cold  or  by 
drugs  or  by  rest.  But  those  are  not  very  important 
points.  They  may  be  important  in  relation  to  what 
we  do  to  help  the  patient,  but  not  in  relation  to  diag- 
nosis. Some  pains,  whatever  their  cause,  are  reheved 
by  cold,  more  by  heat,  and  most  are  also  relieved  by 
rest. 

Next  to  pain,  Cough  is  the  symptom,  especially  in 
the  colder  months  of  the  year,  that  we  have  most  to 
deal  with.  The  question  How  long  ?  is  vastly  the  most 
important  one  about  cough.  One  can  also  measure 
its  severity  by  the  question,  "Does  it  keep  you 
awake?"  and  to  some  extent  by  the  question,  "Does 
it  prevent  work?"  More  important  is  the  question, 
"Is  it  dry  or  productive  of  sputum?"  The  patient's 
description  of  his  sputa  in  gross,  without  any  micro- 
scopic examination,  is  also  of  a  good  deal  of  use. 
There  are  usually  three  things  a  patient  can  tell  us 
about  it:  either  it  is  yellow,  or  it  is  white,  or  it  is 
bloody.  There  are  two  other  important  questions 
about  bloody  sputa.  Unless  one  gets  these  answered, 
the  mere  fact  of  spitting  blood  is  not  important.  We 
must  know  whether  there  are  merely  streaks  of  blood 


42  SOCIAL  WORK 

which  one  often  sees  in  the  sputa  of  anybody  who 
coughs  hard,  are  of  no  importance,  and  have  nothing 
to  do  with  tuberculosis.  But  if,  in  contrast  with  this, 
we  can  really  estabhsh  evidence  of  the  spitting  of 
blood  in  quantity,  we  have  almost  proved  a  diagnosis 
of  tuberculosis.  In  ninety-nine  cases  out  of  one  hun- 
dred the  spitting  of  blood  in  quantity  means  tuber- 
culosis. "  In  quantity"  means  a  cupful  or  thereabouts 
of  pure  blood.  If  the  doctor  does  not  find  tuberculosis 
after  that  he  should  nevertheless  assume  it,  for  it  is 
almost  always  there.  I  should  pay  no  attention  to 
negative  physical  finding  in  such  a  case. 

The  next  point  to  ask  about  is  whether  the  pa- 
tient's breathing  is  wheezy.  When  a  horse  has  be- 
come broken-winded  we  can  hear  his  breathing  in  the 
street  as  he  comes  along.  He  has  become  emphy- 
sematous. We  fmd  this  wheezing  respiration  in  em- 
physema, asthma,  and  bronchitis,  which  are  diseases 
important  for  us  to  distinguish  from  tuberculosis; 
we  almost  never  get  it  in  tuberculosis. 

If  the  patient  complains  of  dyspnea  —  difficult, 
rapid  breathing,  "short  breath"  as  we  say  —  we 
shall  ask  about  oedema  or  swelling  of  any  part,  es- 
pecially of  the  legs. 

In  every  patient  who  has  a  cough  we  are  concerned 
primarily  with  the  diagnosis  of  one  disease,  that  is, 
tuberculosis,  its  presence  or  absence.  Hence  every 
patient  who  coughs  should  be  questioned  about  the 
other  s^nnptoms  of  tuberculosis  and  especially  about 
emaciation.  A  man  with  a  chronic  bronchitis  or  em- 


HISTORY-TAKING  43 

physema  does  not  lose  much  flesh;  he  does  not  be- 
come emaciated.  A  person  does  not  become  thin 
from  throat  trouble.  Hence  emaciation,  especially 
recent,  is  a  helpful  guide  to  the  doctor  in  making  up 
his  mind.  Fever  we  investigate  for  the  same  reason. 
The  only  disease  that  often  causes  cough  and  fever 
during  a  long  period  is  tuberculosis.  Unfortunately 
the  patient's  statement  about  fever  is  usually  unre- 
liable. We  can  beheve  most  of  what  he  says  on  the 
rest  of  these  points.  But  he  does  not  know  whether 
he  has  fever  or  not. 

In  women  we  must  ask  also  about  the  monthly 
sickness,  because  it  is  suppressed  in  cases  of  moder- 
ately advanced  tuberculosis.  Nephritis,  anemia, 
heart  trouble  and  emotional  disturbances  may  have 
that  same  effect.  It  is  a  measure  of  the  degree  of  dis- 
ease, not  its  type. 

For  the  purpose  of  dispensary  consultations  I  do 
not  think  we  should  take  any  family  histories  except 
when  we  suspect  tuberculosis.  But  when  the  history 
leads  us  to  think  that  the  person  may  have  tubercu- 
losis, the  social  worker  can  help  the  doctor  by  asking 
the  patient  questions  about  the  possibility  of  the 
same  disease  in  mother,  father,  or  others  who  are  in 
contact  with  the  patient  —  grandfather,  grand- 
mother, or  other  relatives  or  friends  living  in  the 
same  house.  We  beheve  less  and  less  in  the  heredity 
of  tuberculosis,  more  and  more  in  infection  by  con- 
tact. If  separated  from  a  tuberculous  father  or 
mother  in  early  infancy  we  believe  that  the  child 


44  SOCIAL  WORK 

does  not  acquire  tuberculosis.  But  the  main  mode  of 
infection  is  by  association  in  the  same  house,  over  a 
prolonged  period,  with  people  who  have  tuberculo- 
sis. Often  the  patients  do  not  know  or  will  not  con- 
fess that  anybody  in  the  family  now  has  tuberculosis 
or  has  died  of  it.  But  if  we  can  establish  the  fact  that 
one  of  the  patient's  family  has  died  after  having  a 
cough  for  many  years,  that  he  grew  very  weak,  and 
spit  blood,  we  have  estabhshed  the  diagnosis  with- 
out the  name.  Not  the  degree  of  relationship  to  a 
tuberculous  patient,  but  the  amount  of  time  spent  in 
the  same  house  with  a  tuberculous  individual  —  what 
we  call  the  degree  of  "exposure"  to  tuberculosis  — 
is  the  important  thing. 

Past  history 

After  getting  the  patient's  present  symptoms,  one 
should  ask,  "Were  you  ever  sick  previous  to  this 
illness?  If  so,  what  troubles  have  you  had?"  That  is 
of  use  in  clearing  up  the  limits  or  boundaries  of  the 
present  illness.  The  sicknesses  which  the  patient 
says  he  has  had  are  not  of  very  much  use  to  us  in 
diagnosis  because  we  cannot  get  true  answers.  The 
patient's  diagnoses  or  his  doctor's  are  apt  to  be 
vague  or  meaningless.  But  the  questions  about  the 
patient's  past  history  tend  to  make  him  more  clear 
as  to  the  date  when  his  present  illness  began.  Hence 
his  answers  on  these  points  should  be  written  down 
very  briefly,  a  word  or  two  only  about  each,  and 
usually  in  the  words  used  by  the  patient. 


HISTORY-TAKING  45 

In  our  written  histories  in  hospitals  we  usually 
take  a  considerable  body  of  notes  about  the  patient's 
habits.  I  do  not  advise  this  for  social  workers.  But 
there  are  certain  routine  questions  which  should  be 
asked  of  all  patients  concerning  their  appetite,  bowels, 
sleep,  weight,  and  work.  The  answers  should  be  re- 
corded in  a  separate  paragraph,^  at  the  end  of  the 
history. 

What  is  printed  here  is  meant  to  give  a  sample, 
not  a  full  account,  of  medical-history-taking.  Com- 
petence in  this  field  takes  long  practice.  Neverthe- 
less the  intelligent  social  worker  can  learn  in  a  few 
weeks  to  be  of  great  assistance  to  the  doctor  by  tak- 
ing either  in  the  dispensary  or  in  the  home  such 
histories  as  I  have  sketched. 

In  social-history-taking  there  is  no  single  order  or 
schedule  of  questions  agreed  upon  by  all  social 
workers.  But  there  should  be  some  order  and  system 
determined  partly  by  the  personahty  of  the  worker 
and  partly  by  the  nature  of  the  trouble.  If  poverty 
or  destitution  is  the  presenting  symptom,  one  must 
find  out  the  items  in  the  family  budget,  the  figures 
of  income  and  outgo,  paying  especial  attention  as  in 
medical  histories  to  the  question,  "How  long?"  How 
long  have  you  paid  that  rent,  earned  that  wage,  been 
without  a  job,  taken  boarders,  been  in  debt? 

Is  sickness,  childbirth,  alcoholism,  injury  a  factor? 

Is  there  any  family  history  of  tuberculosis,  pleu- 
risy, insanity,  epilepsy,  feeble-mmdedness?  Of  mis- 


46  SOCIAL  WORK 

carriages  or  of  "scrofulous"  children  and  "blood 
diseases"? 

What  previous  hard  times?  What  economic  and 
moral  high-water  marks  and  low-water  marks  can 
we  trace  in  the  past  history? 

What  relatives,  friends,  employers,  doctors,  teach- 
ers, neighbors,  landlords,  social  agencies,  pubhc  offi- 
cials or  records  can  be  consulted  for  additional  light 
on  the  person  and  his  troubles? 

From  all  these  sources  one  arrives  finally  at  an 
opinion  on  ''what  sort  of  person  are  we  trying  to  help 
—  what  sort  physically,  mentally,  and  morally?" 
That  is  the  central  fact. 


CHAPTER  III 

ECONOMIC  INVESTIGATION  BY  THE  SOCIAL  ASSISTANT 

It  should  be  clear  from  what  I  have  said  already  that 
the  work  of  the  social  assistant  may  have  nothing 
to  do  with  poverty.  Her  only  business  in  visiting  a 
family  may  be  to  assist  the  doctor  in  his  diagnosis 
and  treatment  by  bringing  him  additional  facts 
about  the  nature,  seriousness,  or  cause  of  the  disease 
and  about  the  means  by  which  it  may  be  combated. 

But  in  many,  perhaps  most,  of  the  families  whom 
the  social  assistant  attempts  to  befriend,  there  is  a  call 
for  relief,  for  financial  assistance,  for  money,  food, 
coal,  and  clothes.  This  appeal  hke  most  medical  ap- 
peals is  apt  to  take  the  form  of  an  emergency.  Help 
(we  are  told  over  the  telephone)  is  needed  at  once, 
or  disaster  will  follow.  The  family  is  eager  for  imme- 
diate relief,  not  for  a  slow  and  painstaking  investiga- 
tion of  the  causes  which  have  led  up  to  the  present 
state  of  things,  or  of  the  exact  nature  of  their  present 
troubles.  They  are  like  the  sick  in  this  respect. 
Prompt  reUef  from  pain  is  what  the  sick  demand, 
not  the  tedious  processes  of  questioning  and  exami- 
nation. They  want  a  remedy,  a  pain-killer,  morphine 
or  its  equivalent. 

But  we  all  know  the  dangers  of  giving  morphine 
for  the  relief  of  pain.  It  never  cures  a  disease;  it  only 
stifles  a  symptom.  It  gives  deUcious  ease;  but  the 


48  SOCIAL  WORK 

need  for  its  use  soon  recurs.  Hence  there  is  always 
danger  that  before  long  the  patient  will  have  to 
fight,  not  only  the  disease  which  originally  caused 
him  pain  and  made  him  call  for  morphine,  but  the 
morphine  habit  in  addition.  This  is  all  famihar.  But 
not  ever^^  one  realizes  that  the  giving  of  money  in 
case  of  poverty  is  as  dangerous  as  the  giving  of  mor- 
phiue  in  sickness.  Aloney  like  morphine  satisfies  an 
immediate  need  and  hence  is  eagerly  welcomed  by 
the  sufferer.  But  of  money  as  of  morphine  it  is  true 
that  a  single  dose  soon  makes  the  patient  call  for 
another,  and  often  a  larger  dose;  that  it  soon  makes 
the  patient  dependent  on  this  sort  of  rehef,  and  so 
forms  a  dangerous  habit.  With  the  rarest  exceptions, 
to  give  money  or  to  give  morphine  does  not  cure. 
The  state  of  things  which  produced  the  pain  or  the 
poverty  is  sure  to  recur.  For  I'as  I  have  said  above) 
the  patient's  behef  that  his  present  troubles  are  an 
unforeseeable  accident,  a  sudden  catastrophe,  is  al- 
most never  true.  The  truth  is  that  liis  pain  or  his 
poverty  are  but  the  last  chapters  in  a  long  stor\-  pro- 
duced by  causes  which  can  usually  be  traced  out, 
and  whose  future  action  can  often  be  foreseen.  By 
giving  money  we  are  covering  up  a  smouldering  fire, 
not  quenching  it. 

For  economic  banlvruptcy  or  breakdown,  like  phys- 
ical bankruptcy  or  brealvdowm,  is  generally  the  re- 
sult of  faulty  organization  in  the  system  of  income 
and  expenditure.  Physically  a  person  breaks  down 
because  he  has  been  spending  more  energy  than  he 


ECONOMIC  INVESTIGATION  49 

can  recoup  by  rest,  food,  and  recreation.  Economi- 
cally he  breaks  down  because  his  scale  of  expenses 
exceeds  his  regular  income.  Hence  it  gives  but  tem- 
porary relief  to  pay  the  banlu-upt's  debts,  to  cancel 
the  sufferer's  pain.  The  operation  will  soon  have  to. 
be  done  over  again  unless  some  constructive  plan  for 
increasing  his  income  or  decreasing  his  expenditure 
can  be  worked  out.  Giving  creates  dependence  because 
it  atrophies  industrial  and  moral  initiative,  just  as  a 
crutch  or  a  splint  causes  muscles  to  waste.  Powers 
unused  atrophy.  If  we  support  a  person,  except  tem- 
porarily, he  will  soon  lose  the  power  of  self-support. 
But  the  point  of  view  impressed  upon  us  by  the 
sufferer  himself  is  apt  to  be  quite  the  opposite.  What 
he  wants  is  something  immediate  and  temporary  for 
the  relief  of  something  accidental.  The  beggar  who 
meets  us  in  the  street  has  "accidentally"  lost  his 
purse  and  asks  of  us  a  small  sum  of  money  to  reach 
his  home.  Often  I  have  said  to  such  an  applicant, 
"Meet  me  at  the  railroad  station  half  an  hour  before 
the  train  leaves  for  your  home.  I  will  buy  you  a 
ticket  and  see  you  on  board."  He  never  comes.  This 
is  an  extreme  instance  and  involves  almost  always  a 
deliberate  attempt  to  deceive  us.  In  home  visiting  it 
is  not  hke  this.  The  sufferer  does  not  usually  intend 
to  deceive.  Nevertheless  his  misfortunes  are  pictured 
by  him  as  accidental  and  temporary  catastrophes, 
maiming  a  life  which  needs  no  general  reconstruc- 
tion. He  is  so  sure  of  this  that  he  is  apt  to  force  the 
idea  upon  us  unless  we  are  alert,  bracing  ourselves 


50  SOCIAL  WORK 

to  question  it  and  to  make  sure  that  it  is  true.  But 
actual  experience  has  shown  me  and  hundreds  of 
others  that  this  point  of  view  is  ahnost  never  true. 

It  is  not  chance  that  the  family  is  just  now  poor. 
It  is  no  emergency  which  we  are  summoned  to  meet. 
It  could  have  been  foreseen  long  before  and  it  will 
certainly  recur  imless  we  can  trace  out  its  causes  and 
prevent  their  acting  as  they  have  hitherto.  Hence 
the  detailed,  prolonged,  individual  study  of  the  fam- 
ily's economic  state  is  necessar3\  One  must  find  out, 
first  of  all,  all  the  details  of  income  and  outgo.  The 
family  is  likely  to  forget  some  of  these,  so  that  one 
must  be  ready  to  assist  their  memor^^ 

Further,  one  must  inquire  carefully  into  possible 
sources  of  help  from  relations,  friends,  fellow  mem- 
bers in  some  club  or  association,  and  so  forth.  For 
next  to  self-help  the  help  from  those  naturally 
bound  up  with  one  is  best.  Compared  with  imper- 
sonal charity,  it  is  less  artificial.  It  is  less  destruc- 
tive to  the  natural  family  relationships  which  it  is 
always  our  ultimate  ideal  and  our  immediate  job  to 
maintain  or  to  restore  so  far  as  possible.  Whatever 
disturbs  or  threatens  them  is  hostile  to  the  social 
interests  for  which  we  labor. 

Naturally  one  does  not  invoke  the  help  even  of 
family,  friends,  or  fellow  club  members,  unless  it 
seems  impossible  for  the  individual,  under  the  best 
plan  that  he  and  you  can  think  out  together,  to  get 
along  without  outside  help.  But  if  we  are  convinced 
that,  for  the  present  at  any  rate,  this  financial  self- 


ECONOMIC  INVESTIGATION         51 

maintenance  is  impossible,  it  is  to  securing  help 
from  those  nearest  to  the  sufferer  that  one  should 
look  with  least  regret.  Gifts  or  loans  from  members 
of  his  family  or  from  friends  are  more  likely  to  be 
taken  seriously  by  the  recipient.  He  is  less  hkely  to 
feel  (as  he  does  with  an  impersonal  agency  or  char- 
ity fund)  that  he  can  draw  from  a  bottomless  pit 
of  money  without  making  any  one  else  the  poorer. 
Moreover,  when  he  takes  money  from  his  brother  or 
the  fellow  member  of  some  club,  the  pressure  for  re- 
gaining his  economic  balance  is  likely  to  be  exerted 
from  without  him  as  well  as  from  within.  He  feels 
the  pressure  of  his  debt  and  thereby  is  stimulated 
towards  regaining  his  independence. 

The  sufferer's  "catastrophic"  point  of  view, 
which  tends  to  isolate  the  present  trouble  from  all 
its  causes,  to  represent  it  as  temporary  and  acci- 
dental, is  related  to  his  tendency  to  state  that  he  has 
no  friends,  relations,  or  social  connections  through 
whom  help  could  come  to  him.  Without  any  deliber- 
ate attempt  to  deceive  us,  he  quite  naturally  for- 
gets some  of  his  relations.  He  does  not  want  to  ap- 
peal to  them.  Hence  they  fall  into  the  background  of 
his  mind,  and  are  not  easily  recovered.  When  one 
finds  them  for  him  he  is  apt  to  say,  "I  did  not  think 
of  him  because  I  am  not  on  speaking  terms  with 
him";  or,  "I  would  not  on  any  account  take  money 
from  her,  or  allow  you  to  ask  her  to  help  me."  But 
such  a  sufferer  may  very  properly  be  asked,  "Why  is 
it  that  you  are  wilhng  to  take  money  from  me,  a 


52  SOCIAL  WORK 

stranger,  or  from  this  impersonal  charitable  agency, 
when  you  are  not  willing  to  call  upon  your  own  rela- 
tions nor  even  to  let  them  know  that  you  are  in 
trouble?  You  are  concealing  it  from  them,  are  you 
not?  Is  there  really  any  good  reason  for  this?  Will  it 
not  be  easier  for  you,  as  well  as  for  them,  that  they 
should  know  at  once?  Are  you  not  really  storing  up 
trouble  for  yourself,  postponing  the  evil  day  which, 
when  it  comes,  will  be  worse  than  anything  which 
you  would  have  to  bear  at  present?" 

Of  course,  in  all  such  advice  we  intend  to  say 
nothing  that  we  should  not  wish  to  have  said  to  our- 
selves. The  social  worker  tries  to  treat  people  always 
as  she  would  wish  to  be  treated.  But  one  cannot  al- 
ways avoid  giving  pain  or  even  estrangement.  Be- 
cause such  interviews  are  necessarily  difficult  and 
may  result  in  disaster  to  the  relationship  that  we  are 
trying  to  estabUsh,  they  should  be  postponed  if  pos- 
sible until  we  have  already  established  in  other  ways 
a  friendly  understanding,  a  structure  of  friendship 
which  will  bear  the  strain  of  penetrating  inquiries 
such  as  these  economic  matters  necessarily  entail. 

I  have  said  that  the  first  guide  to  helpful  economic 
relief  is  a  realization  of  its  danger.  The  next  is  aware- 
ness of  the  advantages  of  seif-help  and  the  truth 
that  next  to  self-help,  assistance  from  those  natu- 
rally and  nearly  related  to  one  is  best. 

The  third  principle,  by  following  which  we  may 
hope  to  do  the  greatest  good  and  run  the  least  risk  of 


ECONOMIC  INVESTIGATION         53 

harm  in  our  giving,  is  this :  never  give  hastily  except 
in  extraordinarily  rare  emergencies  such  as  acute 
hunger  or  exposure  to  the  elements.  In  all  other 
cases  give  in  accordance  with  a  plan  worked  out  as 
carefully  as  may  be,  whereby  we  are  confident  that 
our  giving  can  be  temporary.  Sometimes  we  can  ar- 
range that  it  shall  come  to  an  end  automatically. 
That  usually  means  that  we  arrange  for  a  loan  rather 
than  a  gift,  with  repayment  either  by  instalments  or 
in  lump  sum  upon  a  definite  date. 

(a)  Loans.  It  is  in  the  hope  of  rendering  service  by 
these  means  that  there  have  been  organized  philan- 
thropic loan  associations  which  lend  money  at  low 
rates  of  interest  and  sometimes  without  interest  or 
upon  security  which  the  commercial  loan  companies 
would  not  accept.  The  sufferer  with  whom  we  are 
dealing  may  know  nothing  of  the  existence  of  such 
agencies.  If  so,  to  connect  him  with  one  of  them,  to 
help  in  furnishing  the  security  necessary  to  negotiate 
a  loan,  may  perhaps  be  the  best  way  in  which  we  can 
help.  Or  one  may  buy  some  rather  expensive  article 
such  as  a  piece  of  medical  apparatus,  with  the  clear 
understanding  that  we  are  to  be  repaid  in  instal- 
ments or  at  weekly  intervals. 

(b)  Tools  of  a  trade.  Another  example  of  the  kind 
of  giving  which  comes  to  an  end  and  does  not  tend  to 
form  a  habit  like  the  morphine  habit,  is  exemplified 
when  we  buy  a  man  the  necessary  tools  of  his  trade, 
or  the  stock  and  furniture  necessary  to  start  a  store. 
The  belief  on  which  we  rest  in  such  cases  is  that  after 


54  SOCIAL  WORK 

the  initial  act  of  acceptance,  after  an  initial  period 
of  dependence,  the  individual  will  become  self-sup- 
porting and  independent. 

(c)  Furniture.  Or,  again,  one  may  give  or  loan  a 
cooldng-stove,  so  that  the  sufferer  may  no  longer 
have  to  eat  at  restaurants,  or  some  furniture  in  order 
that  he  may  get  the  benefit  of  the  lower  rent  to 
be  had  when  one  hires  an  unfurnished  room.  In  all 
these  cases  the  ideal  thing  is  to  arrange  for  repay- 
ment in  small  instalments.  Faihng  this  we  try  to 
think  out  a  plan  such  that  after  the  original  expendi- 
ture the  sufferer  will  be  able  to  go  on  independently. 

(d)  Aid  in  illness.  A  fourth  example  of  tempo- 
rary interference  in  the  form  of  financial  aid,  is  a  gift 
or  loan  of  money  to  tide  a  person  over  an  ilhiess, 
to  make  his  convalescence  complete  or  to  rest  him 
when  he  is  dangerously  tired.  Usually  such  aid  can 
be  rendered  through  services  or  institutions  (nurses, 
hospitals,  convalescent  homes)  which  do  not  involve 
giving  money  outright. 

(e)  Aid  during  unemployment.  A  fifth  good  reason 
for  giving  money  or  other  forms  of  relief  temporarily 
is  to  tide  the  sufferer  over  a  period  of  unemploy- 
ment, during  which  he  is  actively  looking  for  work 
or  for  better  work  than  he  now  has.  Sometimes  we 
can  assist  him  in  this  search.  But  there  is  danger  in 
this.  A  man  is  less  likely  to  keep  a  job  that  some  one 
else  finds  for  him  than  one  which  he  finds  for  him- 
self. Still,  we  may  help  him  without  harming  him  in 
case  we  can  give  him  facts,  names,  positions,  employ- 


ECONOMIC  INVESTIGATION         55 

ment  agencies  by  means  of  which  he  may  secure  em- 
ployment, he  himself  taking  the  active  part  in  secur- 
ing the  job.  Information,  which  is  what  we  here  fur- 
nish, is  one  of  the  least  dangerous  of  gifts. 

In  all  these  cases  the  principle  is  hke  that  whereby 
we  do  surgery.  Surgery  is  a  temporary  injury  to  the 
body  done  with  the  expectation  of  ultimate  good, 
a  temporary  interference  of  outside  powers  with  the 
natural  self-maintenance  of  the  organism,  in  order 
that  those  functions  may  ultimately  go  on  not  only 
independently,  but  more  satisfactorily  than  before. 
The  surgery  may  kill  the  patient,  or  leave  him  worse 
than  he  was  before.  But  our  reasonable  expectation 
is  (in  case  our  surgery  is  good)  that  his  health  — 
that  is,  the  capacity  of  his  body  to  maintain  itself, 
or  develop  itself  —  will  be  improved.  So  in  economic 
surgery  we  foresee  a  speedy  end  to  the  need  for  aid. 
The  person  is  to  be  put  upon  his  feet  by  our  aid;  our 
services  can  soon  be  dispensed  with.  The  need  will 
not  recur.  It  is  not  chronic.  It  was  not  his  fault  and 
therefore  is  not  hkely  to  return  upon  him  soon  be- 
cause of  continuance  of  the  same  defect. 

Obviously  one  must  try  to  make  clear  —  or,  still 
better,  try  to  have  it  clear  without  explanation,  un- 
derstood because  of  our  previously  estabhshed  rela- 
tion of  trust,  confidence,  and  affection  —  that  it  is 
not  because  of  parsimony  or  close-fistedness  that  we 
are  refusing  to  give  quickly,  constantly,  and  without 
inquiry.  Medical  analogies  must  constantly  guide  us 
and  be  in  the  minds  of  those  whom  we  try  to  help. 


56  SOCIAL  WORK 

We  refuse  money,  as  we  refuse  morphine,  for  the  pa- 
tient's good.  We  try  to  make  our  giving  of  money 
temporary  and  seK-checking,  for  the  same  reason 
that  we  try  never  to  begin  giving  morphine  unless 
we  can  foresee  a  speedy  termination  of  it,  a  speedy 
cessation  of  the  need  for  it,  as  we  do  when  we  give  it 
in  gall-stone  cohc  or  acute  diarrhea,  or  just  before  a 
surgical  operation.  If  morphine  were  a  possession  of 
the  doctor's,  as  money  is  a  possession  of  the  visitor 
or  those  whom  she  represents,  then  the  doctor  might 
often  seem  sting>%  cruel,  selfish  in  his  refusal  to  give 
it.  We  must  make  it  clear  if  we .  can  that  our  hesi- 
tations, limitations,  or  refusals  in  relation  to  money 
have  no  more  connection  with  our  own  control  over 
that  money,  our  o\^ti  enjoyment  of  it,  our  ovvn  sense 
that  we  have  any  right  to  it,  than  the  doctor's  refusal 
to  give  morphine  rests  upon  his  desiring  to  take  the 
morphine  himself  instead  of  giving  it. 

All  this  is  difficult  to  make  clear,  and  it  is  chiefly 
for  this  reason  that  I  have  repeatedly  insisted  that 
the  financial  approach,  the  financial  ground  for  an 
entente  cordiale,  should  not  be  used  early  in  our  deal- 
ings with  the  sufferer,  but  should  if  possible  be  post- 
poned until,  through  medical  service  and  personal 
intimacy,  something  approaching  true  friendship 
has  been  estabhshed. 

It  should  be  clear  from  what  I  have  said  that  our 
judgments  about  giving  financial  aid  can  be  sound, 
can  result  in  doing  good  without  harm  or  (as  in 


ECONOMIC  INVESTIGATION         57 

surgery)  good  with  a  small  element  of  harm,  only 
in  case  they  are  the  fruit  of  detailed,  prolonged,  in- 
dividual study.  It  cannot  be  a  wholesale  matter.  It 
cannot  be  done  in  exactly  the  same  way  in  the  case 
of  any  two  individuals. 

Let  us  stop  to  realize  for  a  moment  how  arduous, 
how  bold  a  task  we  have  undertaken.  We  hope  to 
construct  a  person's  economic  future  better  than  he 
can  construct  it  himself.  We  hope  to  see  what  the  in- 
dividual himself,  despite  the  vividness  and  pressure 
of  his  immediate  need,  has  not  been  able  to  see  for 
himself  —  namely,  how  he  can  get  himself  out  of  his 
financial  difficulties.  We  who  do  not  wear  the  shoe 
are  venturing  to  say  where  it  pinches  and  how  the 
pressure  may  be  relieved,  and  to  know  about  this 
better  than  the  sufferer  who  feels  the  pressure  in  his 
own  person  and  longs  for  its  relief  as  it  is  hardly  pos- 
sible for  any  one  else  to  desire  it.  It  is  almost  as  if  we 
were  trying  to  use  his  mind  for  him.  It  must  not  be 
that.  But  if  it  is  not  to  be  that,  we  must  be  sure  that 
our  aid  is  given  through  stimulating  the  individual 
to  think  for  himself.  "What  do  you  think,"  we  must 
constantly  be  asking  him,  "is  the  best  way  out  of 
this  our  difficulty?"  He  must  feel  that  we  know  it  to 
be  our  difficulty  as  well  as  his,  that  we  are  not  look- 
ing on  with  the  cold  gaze  of  an  outsider,  that  we  suf- 
fer in  his  suffering,  and  still  that  it  is  at  last  his,  and 
that  with  all  our  best  efforts  we  can  only  contribute 
a  little  to  what  must  be  for  the  most  part  his  own 
reconstruction,  a  reconstruction  hke  that  which  the 


58  SOCIAL  WORK 

body  performs  when  it  heals  a  wound  which  the  sur- 
geon or  the  physician  can  only  encourage  a  little 
towards  its  natural  healing. 

Without  being  impudent  enough  to  attempt  to 
use  the  sufferer's  mind  for  him,  to  force  our  wills 
upon  him,  to  take  his  burdens  off  his  shoulders,  to 
fill  his  place  or  to  assume  his  responsibilities,  we 
must  try  to  help  him  in  all  these  respects,  largely  by 
the  kind  of  sympathy  which  stimulates,  the  kind 
of  affection  which  encourages,  the  affection  which 
changes  useless  brooding,  ineffectual  worrying,  de- 
structive grieving,  into  their  opposites.  We  can  help 
him  to  think  by  suggesting  resources,  possibilities 
that  he  does  not  knov>^  or  that  he  has  forgotten,  by 
furnishing  new  material  on  which  his  mind  may 
work,  by  helping  to  generate  the  power,  the  hope, 
the  concentration,  the  prolongation  of  thought  out 
of  which  new  solutions  may  be  born.  He  must  really 
think  of  something  new.  He  must  really  invent 
something,  if  he  is  to  get  upon  his  feet  and  become 
independent  once  more.  Ordinarily  necessity  is  the 
mother  of  invention.  We  pull  ourselves  out  of  our 
difficulties  when  we  finally  realize  that  we  must  be- 
cause disaster  is  otherwise  imminent.  But  such  pres- 
sure of  necessity  as  would  generate  inventiveness  in 
one  person,  may  generate  only  despair  in  another.  It 
is  to  avoid  this  tragedy,  it  is  to  make  fruitful  what 
were  otherwise  fruitless,  that  we  hope  to  warm  the 
sufferer  into  better  life.  We  hope  to  rouse  in  him,  by 
affection  or  by  the  stimulus  of  new  facts  (perhaps). 


ECONOMIC  INVESTIGATION         59 

the  courage  necessary  to  see  his  situation  afresh  and 
to  reshape  it. 

Because  we  are  comfortable  where  he  is  suffering, 
because  we  have  free  power  of  thought  whereas  his 
mind  is  numb  and  cramped,  we  may  be  able  to  think 
of  some  possibilities,  some  changes,  some  sources  of 
hopefulness  which  he  could  not  even  imagine.  He 
cannot  take  them  from  us  ready-made.  If  he  does 
they  will  be  useless  to  him.  But  if  we  have  reached 
the  central  fire  of  his  life,  if  we  have  stimulated  not 
this  faculty  or  that,  but  the  centre  of  his  person- 
ality, then  by  the  grace  of  God  we  may  be  able  to  do 
with  him  what  he  alone  could  not  do. 

Housing 

A  part  of  the  economic  hfe  of  our  patients,  aside 
from  the  food  and  clothes  for  which  they  may  most 
urgently  ask  our  aid,  is  their  housing. 

(a)  Is  it  hygienic? 

(b)  Is  it  as  inexpensive  as  can  be  obtained  with 
due  consideration  of  health,  decency,  distance  from 
work,  from  friends,  from  amusements? 

(c)  Is  it  large  enough  to  safeguard  the  decencies 
of  family  life? 

The  last  of  these  questions  is  the  most  important 
of  all. 

It  should  be  among  the  medical  duties  of  the  visi- 
tor to  investigate  the  hygienic  aspects  of  the  home 
in  order  to  explain  them  to  the  doctor,  who  can  then 


60  SOCIAL  WORK 

include  them  among  the  facts  on  which  his  diag- 
nosis, prognosis,  and  treatment  are  based.  The  so- 
cial worker  may  then  try  to  carry  out  such  improve- 
ments in  housing  as  the  combined  judgment  of  the 
doctor  and  the  social  worker  suggests.  More  im- 
portant than  medicines,  often,  is  the  provision  for 
proper  warmth  and  proper  ventilation  of  the  pa- 
tient's rooms  during  the  day  and  especially  at  night. 
Darkness,  dirt,  poor  ventilation,  favor  the  growth 
of  germs,  vermin,  parasites  of  all  sorts.  They  also  de- 
press the  vigor  and  power  of  the  human  organism  to 
resist  disease.  Doctors  and  social  workers  cannot 
hold  Utopian  views  in  matters  of  housing,  but  must 
content  themselves  with  trying  to  secure  something 
a  little  better  than  they  find  in  the  worst  of  the  pa- 
tient's lodgings,  especially  when  these  lodgings  rep- 
resent conditions  below  the  family's  own  standard  of 
living  at  some  previous  time.  People  adapt  them- 
selves wonderfully  to  bad  hygienic  conditions,  and 
once  so  adapted,  they  may  be  able  to  preserve  their 
health  for  a  long  period.  But  if  then  a  family  is  sud- 
denly forced  to  crowd  itself  into  smaller,  darker, 
dirtier,  noisier  quarters  than  it  has  been  used  to,  or 
if  a  family  group  increases  its  numbers  within  the 
same  quarters,  the  adaptive  powers  of  the  human 
organism  may  be  overstrained  and  break  down. 

It  is  against  these  conditions  especially  that  the 
social  worker  and  the  doctor  should  labor.  Housing 
problems  are  among  the  most  difficult  of  all  that 
confront  society.  Yet  we  should  pledge  ourselves  to 


ECONOMIC  INVESTIGATION         61 

attempt  some  improvement,  not  disdaining  slight 
gains  because  we  are  enamored  of  distant  Utopias. 

Sometimes  people  are  living  beyond  their  means, 
are  accepting  bad  quarters  at  high  prices  when  they 
could  get  as  good  or  better  quarters  for  less  money 
in  some  less  crowded  and  popular  district.  Human 
beings  have  a  strong  tendency  to  stay  wherever  they 
find  themselves,  to  settle  down  by  chance  and  resent 
any  suggestion  of  change  even  for  their  own  greater 
comfort.  After  a  few  months  any  place  soon  comes 
to  have  the  attractions  of  home  merely  because  we 
have  been  there.  Hence  we  stick  in  the  same  place, 
though  we  may  know  that  it  is  chance  and  not  choice 
or  necessity  that  has  put  us  there.  Under  these  con- 
ditions a  social  worker  may  do  real  service  by  her 
greater  knowledge  of  other  lodgings  at  lower  prices, 
or  (what  is  essentially  the  same  thing)  better  lodg- 
ings for  the  same  price  now  paid.  If  the  social  worker 
is  familiar,  as  she  should  be,  with  the  lodging  condi- 
tions in  the  neighborhood  in  which  she  works,  she 
may  be  able  to  give  a  patient  facts  about  lodgings 
which  were  either  unknown  to  him,  or  more  prob- 
ably unrealized,  because  he  has  never  seen  them. 
Our  mental  horizon  becomes  restricted.  Any  one 
who  enlarges  it  by  presentmg  new  and  helpful  pos- 
sibilities serves  us  well. 

So  far  I  have  spoken  of  the  housing  question 
mostly  from  the  standpoint  of  health  or  cheapness, 
but,  as  I  have  already  suggested,  the  moral  aspects 
of  the  problem  are  still  more  important.  It  is  diflfi- 


62  SOCIAL  WORK 

cult,  for  many  impossible,  to  preserve  personal  de- 
cency and  to  keep  family  morality  at  a  proper  level, 
when  adults  and  grown-up  children  are  forced  to 
sleep  in  the  same  room.  Lifelong  injuries  to  body  and 
soul  may  be  forced  upon  innocent  children  in  this 
way.  Nothing  can  be  more  important  than  this.  We 
must  remember,  however,  that  custom  and  previous 
habits  play  a  vast  part  here.  One  race  or  one  set  of 
people  may  have  so  adjusted  themselves  as  to  pre- 
serve decency  under  conditions  impossible  for  an- 
other. We  cannot  generalize.  We  must  know  the 
particular  people  with  whom  we  are  deahng,  and  we 
must  know  their  previous  habits  and  standards  in 
case  they  have  shifted  their  lodging  or  increased  the 
number  of  persons  in  a  room  within  a  short  time,  as 
is  so  frequently  the  case. 

Working  conditions 

Work  and  the  conditions  of  work  are  among  the 
most  important  and  the  most  difficult  of  the  eco- 
nomic problems  in  which  a  social  assistant  may  find 
herself  inevitably  involved.  These  concern  the  pa- 
tient's trade,  the  physical  and  moral  conditions  un- 
der which  he  practises  it,  his  fitness  or  unfitness  for 
it,  the  wages  he  receives,  the  future  possibilities  of 
advancement  in  pay  and  type  of  work  which  it  of- 
fers. In  all  of  these  problems  the  social  worker  can 
sometimes  help  a  little  because  of  her  greater  free- 
dom of  mobility,  mental  and  physical.  She  is  not 
tied  to  her  task  as  blindingly,  as  deafeningly,  as  the 


ECONOMIC  INVESTIGATION         63 

manual  worker  is.  She  may  know  more  or  be  able  to 
find  out  more  as  to  labor  markets,  as  to  other,  pos- 
sibly better,  positions,  shops,  employers.  She  may 
be  able  to  see,  better  than  the  worker  himself,  his 
fitness  or  unfitness  for  the  work  he  is  doing.  She 
may  be  able  to  realize  better  than  he  that  his  trade 
presents  an  impasse,  has  in  it  no  possibihties  of  de- 
velopment, personal  or  financial.  She  may  realize  bet- 
ter than  he  the  bad  effects  of  his  work  upon  health  or 
morality.  In  all  these  respects  she  may  be  able  to 
give  the  safest,  and  in  some  ways  the  most  satisfac- 
tory, of  all  help,  —  namely  information. 

I  do  not  underestimate  the  difficulties  of  such 
help.  It  is  not  easy  to  know  more  about  a  man's 
business  than  he  does.  Yet  if  the  social  worker's 
education,  her  health,  her  circle  of  acquaintances, 
is  greater  than  that  of  the  wage-worker,  she  may 
really  be  of  some  assistance  to  him  even  in  the  field 
that  is  more  specially  his  own  and  that  she  can  un- 
derstand but  superficially.  It  is  for  this  reason  among 
others  that  the  social  worker  cannot  be  too  broadly 
educated,  too  fresh  physically,  too  vigorous  in  her 
powers  of  thought  and  observation,  too  widely 
acquainted  in  her  community. 

Among  the  problems  growing  out  of  the  basal  eco- 
nomic needs  of  which  I  have  just  spoken,  are  others 
with  which  I  cannot  here  deal  adequately.  Such  are: 

(a)  The  problem  of  industrial  hygiene  and  mdus- 
trial  disease. 


64  SOCIAL  WORK 

(b)  The  problems  of  school  hygiene  and  school 
medicine,  since  school  life  is  the  industrial  life  of  the 
child,  who  even  receives  wages  for  going  to  school  in 
some  communities. 

(c)  The  industrial  and  psychological  problems  of 
those  who  are  maimed  by  accident,  war,  or  disease. 

(d)  The  problem  of  industrial  insurance  and 
health  insurance. 

All  of  these  questions  involve  matters  of  State  ac- 
tion, legislative  control,  and  economic  reform  with 
which  I  do  not  wish  to  deal.  But  I  wish  to  make  it 
clear,  in  closing  this  chapter,  that  the  social  worker 
as  a  citizen  is  as  much  interested  in  these  hopes  for 
radical  economic  reforms  as  any  one  else  can  be, 
though  she  does  not  regard  them  as  her  special 
business. 

Preventive  medicine  and  the  daily  fight  against 
individual  cases  of  disease  which  we  hope  some  day 
to  prevent  —  these  two  activities  go  on  side  by  side, 
each  helping  the  other.  The  social  worker  corre- 
sponds to  the  private  practitioner  of  medicine;  the 
economic  reformer  and  discoverer  corresponds  to 
the  laboratory  student  of  preventive  medicine  or  to 
the  public  health  official.  In  social  work  as  in  medi- 
cine the  case  worker  should  bring  to  the  inventor 
and  reformer  new  facts  and  illustrations  suggestive 
of  the  evils  to  be  reformed  or  possibly  of  the  ways  of 
combating  them.  And  in  the  difficult,  often  disap- 
pointing, task  of  trying  to  help  individuals,  the  case 
worker  will  also  take  part  of  his  inspiration  from  the 


ECONOMIC  INVESTIGATION  65 

hopes  and  ideals  of  a  better  economic  order  sketched 
for  him  by  the  legislative  reformer.  The  method  and 
technique  of  economic  investigation  is  complex  and 
difficult.  For  a  masterly  treatment  of  this  and  all 
other  aspects  of  social  diagnosis  Miss  Mary  E.  Rich- 
mond's epoch-making  book  on  "Social  Diagnosis" 
should  be  consulted.  (Published  by  the  Survey  As- 
sociates in  New  York  City.) 


CHAPTER  IV 

MENTAL  INVESTIGATION  BY  THE  SOCIAL  ASSISTANT 

Ever  since  the  days  of  Charcot,  France  has  been 
the  land  of  medical  psychology.  France  has  never 
failed,  as  other  countries  have  failed,  to  take  full 
account  of  the  mental  factors,  the  mental  causes 
and  results  in  disease. 

In  America,  on  the  other  hand,  the  conspicuous 
disregard  of  medical  psychology  by  physicians  has 
led  to  widespread  and  serious  revolt  on  the  part 
of  the  pubhc.  Our  physicians  have  too  often  treated 
the  patient  as  if  he  were  a  walking  disease,  a  body 
without  a  mind.  Medical  psychology  has  been  neg- 
lected in  our  medical  schools  and  in  the  practice  of 
our  most  successful  clinicians.  The  result  has  been 
a  revolt  upon  the  part  of  the  laity,  expressed  in  the 
popularity  of  the  heretical  healing  cults  such  as 
Christian  Science  and  New  Thought.  These  unsci- 
entific and  unchristian  organizations  illustrate  an 
error  opposite  to  that  of  the  physicians,  but  no 
greater  in  degree.  Indeed,  I  think  that  our  physi- 
cians are  more  to  be  blamed  than  the  leaders  of  these 
irrational  cults,  because  our  physicians  having  re- 
ceived a  scientific  training  ought  to  be  more  thor- 
ough, more  unprejudiced,  more  devoted  to  the 
truth,  and  therefore  less  inclined  to  shut  their  eyes 
to  a  huge  body  of  facts.  The  physician  often  shuts 


MENTAL  INVESTIGATION  67 

his  eyes  to  the  existence  of  the  mind  as  a  cause  of 
disease.  The  Christian  Scientist  shuts  his  eyes  to  the 
existence  of  the  body  as  a  cause  of  disease.  Both  are 
equally  and  disastrously  wrong.  But  the  medical 
profession  is  on  the  whole  more  to  blame,  because 
they  ought  to  know  better,  whereas  the  heretical 
heahng  cults  have  grown  up  among  uneducated  men 
who  could  not  be  expected  to  avoid  the  sort  of  nar- 
rowness and  prejudice  from  which  liberal  education 
ought  to  free  us. 

The  situation  in  America,  then,  is  very  different 
and  on  the  whole  worse  than  in  France.  There,  scien- 
tific men,  educated  physicians  have  taken  the  lead- 
ership in  the  field  of  medical  psychology.  In  America 
it  has  been  left  for  ignorant  enthusiasts,  devoid  of 
any  scientific  training  or  breadth  of  culture,  to  press 
upon  our  attention  the  neglected  elements  of  medi- 
cal practice,  and  to  lead  a  revolt  against  the  medical 
profession,  an  anti-scientific  revolution  which  num- 
bers its  adherents  by  milhons.  But  in  neither  coun- 
try has  our  established  knowledge  of  the  mental 
elements  of  disease  been  properly  incorporated  into 
medical  practice,  especially  into  the  practice  of  dis- 
pensary physicians,  and  it  is  here  that  the  social 
worker  forms  an  essential  link  in  the  chain  of  effec- 
tive action.  Let  me  describe  more  completely  what 
I  mean  by  the  mental  element  in  disease. 

I  refer  not  merely  to  the  so-called  nervous  dis- 
eases, the  neuroses  and  psychoses,  the  myriad  forms 
of  nervousness  without  recognizable  basis  in  organic 


68  SOCIAL  WORK 

disease,  but  also  to  the  mental  complications  and  re- 
sults of  serious  organic  diseases  such  as  tuberculosis, 
arteriosclerosis,  and  surgical  injuries.  The  classical 
studies  of  Charcot,  Pierre  Janet,  and  others  have 
made  clear  to  the  whole  world  the  existence  of  a 
body  of  diseases  in  which  the  mental  functions  are 
obviously  deranged  while  still  the  patient  is  not  in- 
sane in  any  legal  sense,  and  does  not  show  on 
physical  examination  any  evidence  of  gross  organic 
disease.  Neurasthenia,  psychasthenia,  hysteria,  are 
among  the  more  common  types  marked  out  by 
the  studies  of  great  psychologists  and  chnicians. 
Little  or  nothing  has  been  added  by  the  studies  of 
German,  American,  and  Enghsh  physicians  to  our 
knowledge  of  these  diseases.  But  throughout  the 
history  and  development  of  France's  leadership  in 
the  study  of  these  diseases,  one  cannot  help  noticing 
that  interest  is  concentrated  largely  upon  diagnosis; 
comparatively  little  attention  is  paid  to  treatment. 
The  great  leaders  have  not  been  extensively  fol- 
lowed. Their  suggestions  have  not  been  carried  out 
on  a  large  scale  nor  followed  sufficiently  into  the 
field  of  practical  therapeutics. 

Especially  is  this  true  in  the  field  of  visceral  neu- 
roses or  nervous  symptoms  referred  by  the  patient 
to  one  or  another  organ  —  the  stomach,  the  pelvic 
organs,  the  bowels  —  in  which  nevertheless  no  evi- 
dence of  disease  can  be  found.  In  these  diseases 
Enghsh,  French,  and  American  physicians  alike  per- 
sist for  the  most  part  in  humoring  and  soothing  the 


MENTAL  INVESTIGATION  69 

patient  by  the  administration  of  remedies  known  to 
have  no  real  influence  upon  disease  and  designed 
chiefly  to  make  the  patient  feel  that  something  is 
being  done  for  him.  This  is  superficial  treatment.  It 
makes  no  attempt  to  attack  the  determining  causes 
of  the  disease.  Whether  or  not  there  are  any  psycho- 
genic diseases,  whether  or  not  purely  psychical 
events  can  be  proved  to  produce  the  group  of  symp- 
toms known  as  neurasthenia,  psychasthenia,  or  hys- 
teria, or  whether  there  are  physical  causes  contrib- 
uting to  produce  the  symptoms,  this  at  any  rate  may 
be  said  with  confidence:  that  if  we  are  to  root  out 
the  patient's  trouble,  if  we  are  to  bring  about  any- 
thing approaching  a  radical  cure,  we  must  attack 
the  mental  symptoms  directly  and  upon  their  own 
grounds,  that  is,  by  mental  means,  chiefly  by  reedu- 
cation. The  mental  element  in  these  diseases  is  at 
any  rate  the  most  vulnerable  point  of  attack.  It  is 
here  that  we  can  most  profitably  exert  therapeutic 
pressure. 

Even  in  organic  disease,  such  as  tuberculosis  or 
arteriosclerosis,  it  may  still  be  true  that  we  can  help 
the  patient  chiefly  through  psychotherapy.  There 
may  be  little  that  we  can  do  for  his  arteries  or  his 
lungs,  and  indeed  the  incurable  destruction  which 
has  gone  on  in  these  organs  may  not  at  the  time  that 
we  are  treating  the  patient  be  producing  any  symp- 
toms. All  his  symptoms  just  now  may  depend  upon 
mental  states  which  we  can  quite  easily  influence 
and  thereby  cure  him  of  all  that  at  present  torments 


70  SOCIAL  WORK 

him,  though  we  recognize  that  the  organic  malady 
remains  untouched,  unimproved.  Many  a  case  of 
tuberculosis  suffers  chiefly  from  his  fears  of  the  dis- 
ease or  from  his  discouragement.  If  we  can  rid  him 
of  his  constant  dread  that  the  disease  will  advance 
or  will  injure  others,  if  we  can  give  him  courage,  the 
natural  healing  power  of  his  tissues  may  be  all  that 
is  needed  to  bring  about  the  arrest  of  the  disease. 
On  the  other  hand,  even  an  incipient  case  of  pul- 
monary tuberculosis  may  go  steadily  on  from  bad  to 
worse,  because  the  patient  is  constantly  fretting  and 
worrying  about  his  own  condition,  or  about  the  pres- 
ent sufferings  of  his  family. 

I  remember  a  case  of  very  early  tuberculosis,  but 
recently  established  at  the  summit  of  one  lung,  but 
unfortunately  occurring  in  a  patient  of  very  active 
temperament,  prone  to  fume  and  worry  the  instant 
that  he  was  taken  away  from  his  work.  He  was  de- 
voted to  his  family,  but  as  soon  as  he  was  aware  of 
his  trouble,  he  could  think  of  them  only  as  doomed  to 
be  dragged  down  by  the  contagion  of  his  own  disease 
or  by  the  poverty  resulting  from  his  own  inactivity. 
Unfortunately,  no  proper  study  was  made  of  this 
patient's  malady.  No  account  was  taken  of  his  char- 
acter and  temperament.  The  condition  of  his  lung 
occupied  the  whole  field  of  the  physician's  vision. 
The  condition  of  that  lung  demanded  for  the  patient 
isolation  and  complete  rest  in  a  sanatorium.  This 
was  prescribed  and  carried  out.  The  patient  re- 
mained in  the  sanatorium  about  two  months,  fum- 


MENTAL  INVESTIGATION  71 

ing  and  worrying  constantly.  He  then  refused  to 
stay  any  longer,  left  the  institution  against  the  ad- 
vice of  his  physician,  returned  to  his  family,  and  died 
about  two  months  later. 

Now  I  think  it  is  at  least  probable  that  had  we 
studied  the  patient's  mind  as  carefully  as  we  studied 
his  lung  in  this  case,  his  life  might  have  been  saved. 
But  the  physician  who  made  the  diagnosis  and  pre- 
scribed the  treatment  could  spend  but  a  few  minutes 
upon  the  case,  which  formed  but  one  of  many  troop- 
ing past  him  in  his  consultation  hour  at  the  dispen- 
sary. He  had  no  time  for  the  prolonged,  detailed, 
wearisome  studies  necessary  to  win  this  patient's 
confidence,  to  make  him  feel  that  he  was  wholly  un- 
derstood, and  bring  him  to  the  point  when  he  would 
let  himself  be  reeducated  upon  the  mental  side  and 
receive  docilely  the  advice  given  him.  This  work 
should  have  been  carried  out  by  the  right  type  of 
social  worker.  Such  a  visitor  would  no  doubt  have 
realized  that  one  must  compromise  to  a  certain  ex- 
tent with  the  difficulties  of  the  patient's  tempera- 
ment. One  must  adapt  and  modify  the  treatment 
suitable  for  the  average  case  because  this  particular 
patient  differs  from  many  others  in  important  re- 
spects. 

In  the  first  place,  he  must  be  made  to  understand 
the  importance  of  a  correct  mental  attitude  for  the 
cure  of  his  disease,  must  be  taught  that  his  recovery 
depends  to  a  considerable  extent  upon  his  own  efforts 
at  seK-control  and  self-education.  Next  he  must  be 


72  SOCIAL  WORK 

convinced  that  his  family  will  be  adequately  cared 
for  during  his  absence  from  work.  Furthermore,  the 
complete  rest  in  bed  which  would  probably  be  ad- 
visable for  him  if  one  had  only  the  condition  of 
his  lung  to  consider,  should  probably  in  his  case 
be  modified  owing  to  the  fact  that  his  mental  state 
makes  it  impossible  for  him  to  rest  when  he  is  con- 
fined to  bed.  In  such  cases  one  has  the  outward 
appearances  of  repose  but  not  the  reaUty,  one  clings 
to  the  form  but  misses  the  substance.  What  one 
has  prescribed  is  in  reahty  enforced  impatience,  en- 
forced restlessness,  because  one  has  put  the  patient 
under  a  regime  where  no  result  can  be  expected  ex- 
cept impatient  struggling  against  restraint.  Such  a 
patient  should  be  allowed  a  certain  amount  of  work, 
carefully  chosen  and  supervised,  so  as  not  to  exer- 
cise the  larger  muscles  of  the  body  and  thus  produce 
fever,  but  sufficient  to  occupy  an  active  mind  and  to 
make  the  patient  forget  himself.  To  find  such  occu- 
pation is  difficult,  no  doubt,  but  it  is  not  impossible. 
I  have  seen  it  done.  In  the  case  which  I  am  now  con- 
sidering, no  such  effort  was  made.  The  patient  was 
excessively  lonely  and  isolated  in  the  sanatorium  to 
which  he  was  sent.  The  doctor's  visits  were  occupied 
with  physical  examination  and  the  reiteration  of 
commands  that  he  should  stop  worrymg  and  remain 
completely  at  rest. 

Such  treatment  violated  grossly  one  of  the  basal 
laws  of  medical  psycholog>%  which  recognizes  that 
no  one  ever  stops  worrying  because  he  is  told  to  do 


MENTAL  INVESTIGATION  73 

so.  To  give  such  a  command  is  as  irrational  as  to  tell 
an  epileptic  not  to  have  convulsions  or  a  choreic  pa- 
tient not  to  wriggle  his  hands.  Yet  this  sort  of  error 
is  constantly  committed  by  physicians  who  have 
been  well  trained  to  understand  the  physical  changes 
of  disease,  but  have  never  concerned  themselves  to 
recognize  the  simplest  and  most  obvious  facts  about 
the  mental  condition  of  the  sick.  As  I  have  already 
said,  it  is  impossible  for  the  dispensary  doctor  to  be- 
come acquainted  with  the  details  of  the  patient's 
malady,  or  to  find  out  by  investigation  and  experi- 
ment how  the  patient's  mind  may  be  made  to  aid  his 
recovery  rather  than  to  impede  it.  This  is  the  proper 
task  for  a  social  worker,  partly  because  she  has  more 
time,  partly  because  she  is  a  woman,  and  is  for  that 
reason  more  fitted  to  get  into  close  touch  with  the 
patient's  mind  and  to  use  skill  and  tact  in  manag- 
ing him. 

Such  studies  of  the  social  worker  are  equally  im- 
portant in  the  case  of  the  functional  neuroses;  for 
example,  in  the  cases  where  the  patient's  troubles 
can  be  most  effectively  attacked  by  ridding  him  of 
his  fears.  Fear  plays  a  dominant  role  in  the  suffer- 
ings of  many  cases  both  of  organic  and  of  functional 
disease.  In  a  recent  examination  of  six  hundred  and 
sixty-two  young  men  about  to  enter  Harvard  Uni- 
versity, it  was  found  that  "there  were  more  boys  who 
thought  they  had  a  serious  organic  defect,  usually 
of  the  heart,  and  were  found  entirely  sound  than  boys 
who  thought  they  were  well  and  had  disease."  They 


74'  SOCIAL  WORK 

had  been  threatened  '^ith'  heart  disease  by  g^nina- 
sium  instructors  or  ill-trained  physicians.  They  had 
in  consequence  restricted  their  physical  activities  and 
been  haunted  by  the  fear  that  they  might  by  some 
unusual  exercise  of  mind  or  body  make  themselves 
seriously  ill  or  perhaps  suddenly  die.  Such  fears 
were  all  the  more  disastrous  in  these  young  men  for 
being  only  half  realized  by  themselves.  It  is  exactly 
these  shadowy  apprehensions,  these  dreads  which 
dwell  in  the  half  hght,  never  quite  faced  in  full  con- 
sciousness, which  torment  and  incapacitate  us  the 
most.  Careful  physical  examination  showed  that  the 
young  men  just  referred  to  were  free  from  all  disease, 
and  the  clear  and  emphatic  statement  of  this  fact 
rendered  a  prompt  and  important  ser\ice. 

But  if  such  fears  haunt  the  students  about  to  en- 
ter Har\'ard  College,  who  are  young  men  drawn  from 
the  better  educated  and  more  well-to-do  classes,  we 
may  be  sure  that  fear  plays  even  a  larger  part  in 
producing  the  sufferings  of  patients  such  as  we  ex- 
amine and  treat  in  a  pubhc  dispensar^^  For  such 
patients  are  very  apt  to  be  influenced  by  ground- 
less rumors,  panics,  neighborhood  gossip.  They  are 
prone  to  beUeve  medical  lies  which  the^''  read  in 
newspapers  and  in  the  leaflets  and  circulars  sent 
to  them  by  charlatans.  Almost  all  theh  medical 
education  comes  to  them  from  such  sources,  and 
is  made  up  of  a  mass  of  systematic  falsehoods  de- 
signed to  excite  fear  and  to  produce  s\'mptoms  by 
suggestion. 


MENTAL  INVESTIGATION  75 

Now  if  it  is  true  that  even  among  educated  and 
relatively  self-conscious  classes  the  most  trouble- 
some and  incapacitating  fears  are  those  which  are 
but  dimly  known  to  the  patient  himself,  this  is  sure 
to  be  still  more  frequently  the  case  among  dispen- 
sary patients.  It  is  especially  difficult  and  especially 
important,  therefore,  that  their  fears  should  be  un- 
derstood and  brought  to  light  through  the  investiga- 
tions of  some  one  who  has  time,  patience,  and  tact  to 
devote  to  the  task.  This  cannot  be  the  task  of  the 
physician  who  sees  neurological  cases  in  the  dispen- 
sary, any  more  than  the  psychological  twists  and 
tangles  of  the  tuberculous  patient  can  be  followed 
out  by  the  speciahst  in  tuberculosis  who  examines 
the  patient's  lungs.  It  is  the  proper  task  of  the  social 
worker.  When  she  has  brought  the  patient's  fears  to 
light,  when  she  understands  the  details  of  his  mal- 
ady, she  can  communicate  these  facts  to  the  physi- 
cian. He  then  can  exorcise  the  unclean  spirits  with 
the  full  authority  of  his  medical  position. 

Just  here  one  sees  a  good  example  of  the  proper 
cooperation  between  the  physician  and  the  social 
worker  in  the  dispensary.  Each  brings  to  hght  cer- 
tain elements  in  the  diagnosis.  But  in  the  end  the 
physician  must  unite  all  the  knowledge  accumulated 
either  by  himself  or  by  his  social  assistants,  and 
thus  must  be  enabled  to  act  for  the  patient's  benefit 
on  the  basis  of  a  body  of  information  much  larger 
than  he  could  have  secured  alone. 

The  social  worker  is  also  an  essential  aid  to  the 


76  SOCIAL  WORK 

physician  in  bringing  to  light  the  mental  torments 
and  errors  which  result  from  difficult  personal  rela- 
tions within  the  family.  These  difficulties  can  only 
be  understood  by  one  who  visits  the  patient  in  his 
home,  becomes  intimate  and  friendly  with  other 
members  of  his  family,  and  understands,  therefore, 
the  difficulties  that  may  arise  from  friction,  rivalry, 
jealousy,  and  temperamental  incompatibility  within 
the  home.  In  some  cases  the  patient's  friends  and 
companions  in  work  or  school  must  also  be  under- 
stood. In  other  words,  one  must  take  account  of  the 
totality  of  influences  in  the  patient's  environment, 
the  physical  influences  of  nutrition,  ventilation,  cloth- 
ing, but  also  the  psychical  influences  exerted  upon 
him  by  his  family  and  friends,  by  his  own  half-con- 
scious thoughts,  by  his  worries,  his  remorse,  his  fears. 
Many  a  case  of  stomach  trouble  cannot  be  cured  by 
diet  or  remedies  until  one  can  find  out  what  it  is  that 
the  patient  is  worrying  about  and  can  enable  him  to 
combat  and  subdue  his  mental  enemies.  Innumera- 
ble vague  pains  which  the  doctor  cannot  attribute 
to  any  organic  disease,  and  for  which  the  use  of 
drugs  is  only  too  likely  to  do  harm,  yield  only  when 
one  can  study  and  influence  the  whole  extent  of  the 
patient's  mental,  moral,  and  spiritual  life.  Nothing 
can  be  excluded  here.  It  is  utterly  unscientific  to 
close  our  eyes  to  any  human  interest,  no  matter  how 
little  we  may  sympathize  with  it  personally.  It  is 
one  of  the  facts  of  the  case,  and  must  be  understood 
and  allowed  for  in  our  treatment. 


MENTAL  INVESTIGATION  77 

More  and  more  frequently  in  America  the  dispen- 
sary physician  is  consulted  about  the  physical  and 
mental  condition  of  children  and  adolescents  who 
are  sent  to  htm  from  courts.  The  judges,  especially 
in  our  juvenile  courts,  are  coming  to  realize  that 
their  legal  training,  their  knowledge  of  the  nature, 
the  evidence,  and  the  prescribed  punishments  for 
proved  offences,  is  only  a  small  part  of  their  equip- 
ment if  they  are  to  deal  with  juvenile  offenders  in 
such  a  way  as  to  promote  the  public  good.  The  legal 
profession  is  beginning  to  realize  that  the  physical, 
mental,  and  moral  study  of  juvenile  offenders  is  es- 
sential if  one  is  to  do  anything  to  prevent  their  offend- 
ing again.  If  penology  is  to  be  constructive  and  re- 
formatory, if  it  is  not  merely  to  represent  revenge, 
repression,  and  intimidation,  our  judges  must  know 
something  of  medicine  and  especially  of  medical 
psychology.  In  this  field,  as  in  the  field  of  the  func- 
tional and  visceral  neuroses,  France  has  furnished 
the  leaders,  but  apparently  these  leaders  have  been 
insufficiently  followed.  The  work  of  Binet  in  the  psy- 
chological measurements  of  school-children's  intelli- 
gence seems  to  us  in  America  to  have  been  epoch- 
making.  We  recognize  its  limitations,  we  recognize 
that  in  its  details  it  cannot  be  universally  followed. 
But  we  have  taken  up  the  suggestions  and  the 
method  of  Binet,  and  gratefully  acknowledging  our 
indebtedness  to  him  we  have  tried  to  carry  these 
suggestions  and  methods  much  further,  to  apply 
them  to  the  needs  of  older  children  and  to  the  exami- 


78  SOCIAL  WORK 

nation  of  those  who  cannot  read  and  write.  Binet's 
tests  depended  altogether  too  much  upon  the  use  of 
books  and  upon  hnguistic  facihty.  Yet  with  some 
modifications  they  seem  to  us  in  America  to  be  of 
the  greatest  value,  and  in  the  remarkable  book  The 
Individual  Delinquent  (Macmillan  Co.)  by  Dr.  Wil- 
liam Healy,  of  Boston,  and  in  the  books  of  his  as- 
sociates and  followers,  the  science  of  medicine  and 
medical  psychology  are  intimately  interwoven  with 
the  investigations  and  reports  of  the  social  worker. 

In  the  first  of  the  books  to  which  I  have  just  referred, 
Dr.  Healy  presents  in  detail  the  cases  of  over  three 
hundred  children  who  were  sent  to  him  as  a  physician 
and  medical  psychologist  by  the  judge  of  the  Juve- 
nile Court  in  Chicago,  who  requested  Dr.  Healy  to 
aid  him  in  his  legal  treatment  through  a  medical  and 
psychological  study  of  each  case.  Dr.  Healy  with  his 
corps  of  assistants  and  social  workers  studied  in  each 
child  the  physical  condition,  especially  the  presence 
or  absence  of  defects  of  sight  and  hearing,  and  the 
mental  condition  carefully  measured  by  tests  based 
upon  those  of  Binet,  but  extended  considerably  by 
Dr.  Healy  himself  and  by  others.  But  he  adds  to 
the  facts  thus  ascertained  a  careful  investigation  of 
the  child's  social  environment,  both  physical  and 
psychological;  that  is,  of  all  the  influences  —  heredi- 
tary, domestic,  economic,  industrial,  and  personal 
—  which  have  contributed  to  lead  the  child  into 
crime.  The  influence  of  other  boys  and  girls  of  the 
same  age,  of  associates  in  work  or  school,  is  investi- 


MENTAL  INVESTIGATION  79 

gated;  also  the  good  or  bad  example  of  parents,  the 
amount  and  quality  of  schooling,  and  the  presence 
or  absence  of  religious  instruction. 

All  these  latter  investigations  are  carried  out  for 
Dr.  Healy  by  social  workers.  Their  results  are  then 
pooled  with  those  obtained  by  him  after  the  physi- 
cal and  psychical  examination  of  the  child  at  the  dis- 
pensary. 

One  sees,  then,  that  Dr.  Healy  and  the  other 
Americans  who  have  followed  him  in  this  field,  in- 
sist upon  covering  in  every  case  four  classes  of  facts: 

(1)  The  child's  physical  condition. 

(2)  The  child's  mental  condition. 

(3)  His  physical  environment. 

(4)  His  mental,  moral,  and  spiritual  environ- 
ment. 

All  this  investigation  is  necessary  because  it  is 
now  recognized  that  crime  may  be  committed  be- 
cause the  child  is  an  epileptic;  because  he  is  feeble- 
minded; because  he  is  strained  and  tortured  by  de- 
fects of  sight  and  hearing;  by  inabihty  to  keep  up  in 
school  on  account  of  these  defects;  because  he  is  ab- 
normally susceptible,  under  the  influence  of  com- 
rades, cinema  shows,  and  sensational  literature;  be- 
cause his  inheritance,  his  education,  or  his  home 
training  has  been  defective  or  bad. 

Since  there  is  no  reasonable  doubt  that  physicians 
and  judges  will  more  and  more  cooperate  in  the  study 
of  offences  against  the  law,  and  will  more  and  more 
need  the  assistance  of  social  workers  to  complete 


80  SOCIAL  WORK 

their  studies  and  to  carry  out  the  reforms  which 
those  studies  suggest,  it  can  easily  be  appreciated 
that  the  social  workers  need  to  be  famihar  with  the 
methods  and  results  of  psychological  examination  in 
this  field  of  work. 

Mental  diagnoses  in  social  work 

The  idea  that  social  work  necessarily  concerns  the 
poor  is  wholly  wrong.  It  concerns  the  sick;  it  con- 
cerns the  tuberculous;  some  of  the  sick  and  some  of 
the  tuberculous  are  poor.  Others  are  not.  The  State 
provides  dispensaries  for  tuberculosis,  and  the  peo- 
ple pay  for  them  out  of  the  taxes.  Hence  all  the  peo- 
ple feel  that  they  have  the  right  to  go  there  and  that 
they  are  not  in  any  sense  accepting  charity  in  going 
there.  But  social  work  is  done  in  all  these  dispen- 
saries. Thus  the  connection  between  medical  and 
social  studies  is  tending  to  upset  the  old  idea  that 
social  work  is  necessarily  concerned  with  poverty, 
and  that  economic  studies  are  the  main  part  of  it. 

In  America  our  leading  ideas  about  social  work 
(formerly  called  charity),  came  originally  from  Eng- 
land and  from  the  studies  of  English  economists. 
Hence  to  a  considerable  extent  economic  consider- 
ations have  governed  the  history  and  evolution  of 
social  work  even  up  to  the  present  day.  Economists 
and  people  interested  especially  in  pohtical  econ- 
omy have  studied,  practised,  and  spoken  and  writ- 
ten upon  these  subjects,  and  all  who  are  governed  by 
the  traditions  inherited  from  England  are  still  ob- 


MENTAL  INVESTIGATION  81 

sessed  by  the  idea  that  money  and  money  troubles 
are  the  gist  of  social  work. 

Nobody  should  turn  up  his  nose  at  economics. 
Anybody  who  is  careless  in  money  matters  is  sure 
to  come  to  grief.  But  in  my  medical-social  work, 
which  has  included  a  large  number  of  cases  where 
poverty  existed,  I  have  ahnost  never  found  the  eco- 
nomic trouble  to  be  the  essential  one.  Economics  is 
everywhere  present,  everywhere  subordinate.  That 
is  an  adaptation  of  a  saying  of  the  German  phi- 
losopher Lotze:  "Mechanism  everywhere  present, 
everywhere  subordinate."  The  idea  applies  also  to 
economics  which  has  many  qualities  in  common  with 
mechanics. '  I  shall  therefore  lay  especial  stress  in 
this  book,  not  upon  economic  but  mental  deficien- 
cies, which  in  most  cases  seem  to  me  more  funda- 
mental than  economic  need  or  physical  weakness. 

A  considerable  portion  of  all  social  diagnoses 
should  contain  the  word  ignorance.  I  wish  to  dis- 
tinguish ignorance  from  moral  fault.  It  is  true  that 
somebody's  sin,  somebody's  evil-doing  is  the  funda- 
mental thing  in  the  social  diagnosis  of  many  cases. 
I  have  never  yet  studied  carefully  a  case  involving 
social  work  without  finding  some  moral  weakness 
as  an  important  element  in  the  trouble.  Moral  ele- 
ments always  enter  into  the  study  of  a  case  of  social 
work,  but  they  are  often  not  the  main  element,  often 
subordinate. 

Ignorance,  of  course,  is  permanent.  If  we  were  not 
ignorant  we  should  never  progress.  Ignorance  there- 


82  SOCIAL  WORK 

fore  does  not  necessarily  mean  culpable  ignorance, 
but  still  it  may  be  the  keynote  to  the  trouble  in 
which  any  of  us  finds  himself.  Consider  industrial 
ignorance,  ignorance  of  where  best  to  turn  one's 
forces.  It  would  be  impossible  to  say  that  any  of  us 
is  free  from  that.  Are  we  perfectly  sure  that  we  have 
found  the  place  where  the  Lord  intended  us  to  work? 
This  lack  may  not  be  such  as  to  bring  us  into  trouble. 
It  may  not  force  us  to  seek  social  aid.  Yet  the  lack  of 
a  clear  idea  about  where  we  ought  to  be  working, 
how  we  can  earn  the  most  money,  do  the  most  good, 
and  be  happiest  —  that  is  a  deficiency  that  none  of 
us  is  free  from. 

Industrial  ignorance  has  been  the  ultimate  diagno- 
sis in  some  of  the  cases  that  I  have  studied.  The  pa- 
tient is  an  industrial  misfit.  He  has  not  found  his 
niche.  Perhaps  there  is  no  niche  existing  for  him. 
Some  people  seem  to  be  made  for  another  planet  or 
another  century.  Evidently,  then,  conception  of  an 
industrial  misfit  is  wide,  perhaps  vague.  Yet  it  often 
dominates  the  economic  situation.  Your  patient 
perhaps  cannot  earn  his  hving  because  he  is  working 
with  only  about  one  quarter  of  his  powers,  and  that 
the  least  useful  quarter.  That  with  which  he  is  try- 
ing to  earn  his  living  may  be  a  mere  superficiaHty. 
HaK  the  women  that  I  know  in  industry  are  working 
with  a  wholly  superficial  part  of  themselves,  uncon- 
nected with  any  of  their  deepest  interests.  That  is 
less  true  of  social  workers  than  of  any  other  body  of 
women.  They  often  can  put  the  best  of  themselves 


MENTAL  INVESTIGATION  83 

into  their  work.  But  many  women  in  industry,  in 
business,  hate  it.  They  may  be  earning  enough,  but 
are  unhappy  and  unsatisfied,  because  the  powers 
with  which  they  were  meant  to  labor  for  the  service 
of  their  kind  are  not  being  used  at  all. 

Medical  ignorance:  A  quarter,  perhaps,  of  our 
task  as  social  workers,  is  medical  instruction,  the 
breaking-up  of  medical  ignorance.  Most  well-trained 
physicians  of  the  present  day  do  not  beheve  that 
many  diseases  can  be  cured  by  medicine  or  by  sur- 
gery. We  do  not  have  great  confidence  in  chemical, 
physical,  or  electrical  therapeutics.  We  beheve  that 
when  sick  people  are  helped  by  a  medical  man  or  a 
social  worker  it  is  because  they  have  learned  some- 
thing of  what  we  call  how  to  live,  a  large  term  which 
we  usually  hmit  to  mean  how  to  look  after  their 
physical  machine. 

As  I  talk  with  supposedly  educated  people,  I  am 
amazed  to  see  how  little  people  who  have  lived  forty 
or  fifty  years  in  the  same  tenement  of  clay  have 
learned  about  that  structure.  I  do  not  mean  that 
everybody  ought  to  study  physiology.  I  mean,  for 
example,  such  a  simple  thing  as  how  to  rest.  One  can- 
not rest  just  as  somebody  else  rests.  We  have  indi- 
vidual finger-prints,  no  two  alike,  and  individual 
hand-writing.  So  we  have  —  and  should  have  found 
—  our  own  way  of  working  and  of  resting,  which  is 
probably  as  individual  as  our  finger-prints.  But  we 
follow  each  other  hke  sheep. 

The  instructions  we  give  to  a  tuberculous  patient 


84  SOCIAL  WORK 

are  needed  because  of  his  medical  ignorance  or  that  of 
others.  I  once  received  a  wonderfully  touching  letter 
from  a  middle-aged  tuberculous  lawyer  who  finally 
learned  the  medical  facts  necessary  to  save  his  life 
through  reading  a  popular  magazine.  He  was  being 
treated  for  tuberculosis,  about  as  badly  as  a  human 
being  could  be  treated,  but  he  did  not  1-mow  this.  He 
had  gone  to  the  best  doctor  in  his  vicinity.  Through 
reading  in  a  popular  magazine  an  account  of  a  medi- 
cal conference  on  the  treatment  of  tuberculosis  he 
finally  learned  the  truth  and  cured  himself.  Medical 
ignorance  in  relation  to  diabetes,  to  stomach  trou- 
ble, to  venereal  disease,  to  heart  disease,  it  may  be 
one  of  our  tasks  to  remove  before  inculcating  the 
regime  needed  in  these  troubles. 

Educational  ignorance,  ignorance  of  proper  institu- 
tions and  methods  to  give  a  man  the  power  which  he 
needs,  is  often  exemplified  in  relation  to  industrial 
training.  One  sees  people  in  industr^^  who  could  do  a 
great  deal  better  work  if  they  had  better  training. 
But  they  do  not  know  where  to  get  it.  In  many  cities 
there  are  scholarships  and  funds  for  people  who 
show  ambition  to  be  better  trained.  Educational  ig- 
norance, then,  as  well  as  industrial  and  medical 
ignorance,  may  bring  people  into  economic  trouble, 
even  into  physical  trouble.  Such  people  often  turn 
up  at  a  dispensan^  asking  the  doctor  merely  to  cure 
a  headache  or  a  stomach-ache.  Yet  if  the  doctor  is 
Vvise  he  ^ill  find  this  other  trouble  hidden  in  the 
background. 


MENTAL  INVESTIGATION  85 

Obviously  ignorance  as  a  cause  of  trouble  is  a  his- 
toric, not  a  catastrophic,  cause.  Ignorance  does  not 
happen  suddenly.  Its  bad  results  accumulate  gradu- 
ally. 

Shiftlessness 

Another  mental  element  in  social  diagnosis  I  call 
shiftlessness,  in  a  particular  sense  that  I  want  to  de- 
fine. Not  shiftlessness  in  the  sense  of  a  general  moral 
accusation,  but  as  a  failure  of  adjustment  —  malad- 
justment, due  to  shiftlessness  in  the  sense  of  an  in- 
abihty  to  shift  when  there  is  a  need  for  it.  Professor 
Edouard  Fuster  ^  has  spoken  of  social  treatment  as 
consisting  almost  entirely  of  helping  people  towards 
a  better  self-adjustment  to  their  actual  or  attainable 
environment.  People  often  make  a  failure  of  their 
lives  because  they  do  not  shift  when  the  proper  time 
arrives.  There  are  also  people  who  shift  too  often,  on 
the  other  hand.  I  shall  speak  of  that  later. 

The  physical  analogies  of  these  mental  faults  are 
interesting,  I  think.  A  person  who  has  too  great  phys- 
ical shiftlessness  gets  a  bed-sore.  Healthy  people 
when  they  have  lain  in  a  certain  position  in  bed  for  a 
time  feel  a  discomfort  and  therefore  instinctively 
turn  over.  We  shift  ourselves  now  and  then  in  our 
chairs  as  we  sit,  and  thus  we  relieve  pressure  which 
in  turn  would  produce  injury.  But  in  chronic  illness 
the  patient  sometimes  lies  in  one  position  so  long 
that  he  wears  out  his  tissues  till  the  raw  flesh  or  even 

^  Conference  Interalliee  des  Mutiles.  Peiris,  May,  19 17. 


86  SOCIAL  WORK 

the  bone  is  exposed.  That  is  just  as  true  on  the  men- 
tal side  of  hfe,  true  of  us  all. 

There  is  nothing  I  hate  more  than  seeming  to  take 
a  Pharisaical  attitude  in  our  social  diagnoses.  All  of 
us  probably  have  failed  to  shift  when  we  should.  We 
might  be  more  useful  to-day  if  we  had  shifted  more 
wisely.  Still,  we  are  getting  along  somehow,  and 
some  other  people  come  to  us  for  advice  because 
they  are  even  more  shiftless  than  we.  I  never  yet 
made  a  social  diagnosis  in  anybody  that  I  could  not 
make  also  in  myself.  It  is  only  a  question  of  degree. 

Industrial  shiftlessness  is  an  obvious  example.  A 
person  gets  into  the  wrong  job  and  then  does  not  get 
out  of  it.  Most  people  choose  their  professions  by 
the  most  irrational  process  or  lack  of  process  that 
can  be  conceived  of.  When  a  boy  is  ready  to  choose 
a  profession,  does  he  look  around  him,  study  the  al- 
ternatives, and  select  one?  Not  at  all.  He  does  what 
the  next  man  does,  what  his  father  did,  what  he  hap- 
pens to  have  heard  most  about.  This  is  true  w^hether 
people  are  pressed  for  money  or  not.  They  choose 
their  job  for  no  good  reason;  they  are  thrown  into 
work  by  something  pretty  near  to  "chance."  But 
they  are  often  saved  from  the  full  consequence  of 
their  mindlessness  because  they  shift.  They  shift 
either  within  the  job  or  into  another  job.  I  got  into 
medicine  first  on  the  laboratory  side,  began  by  writ- 
ing a  book  on  the  blood  and  doing  an  unconscionable 
amount  of  work  in  the  laboratory.  It  was  wrong.  I 
was  not  fitted  for  it,  and  luckily  I  knew  enough  to 


MENTAL  INVESTIGATION  87 

shift.  Social  medicine  was  what  I  wanted.  So  many  a 
man  shifts  within  his  profession.  That  is  why  the 
wrong  choice  made  at  the  start  does  not  always  get 
people  into  serious  trouble.  But  the  chronically  shift- 
less man  remains  immobile.  He  does  not  know  where 
else  he  might  be  besides  the  place  where  he  is.  So  he 
stays  where  he  happens  first  to  fall,  gets  bitter,  hard, 
poor,  drunken,  all  because  he  is  in  the  wrong  niche. 

One  sees  racial  shiftlessness  when  people  cross  the 
ocean  and  try  to  take  root  in  a  new  country.  This 
racial  non-adjustment  has  very  tragic  results.  V/e 
see  it,  for  example,  in  the  Armenians  in  America 
who  have  come  from  a  civilization  two  centuries 
back,  and  cannot  jump  these  two  centuries.  Hence 
comes  the  breaking-up  of  moral  and  industrial  stand- 
ards because  they  have  come  suddenly  into  a  civili- 
zation to  which  they  cannot  adapt  themselves. 

A  third  kind  of  shiftlessness  one  might  call  domes- 
tic shiftlessness.  An  English  servant  girl  married  an 
Itahan  fruit-dealer.  She  was  taken  home  into  his 
Italian  family  in  Boston  and  had  to  try  to  fit  herself 
to  Itahan  customs.  She  and  her  husband  got  along 
excellently.  But  it  was  very  hard  for  her  to  under- 
stand the  shifts  which  she  must  make  in  order  to 
adapt  herself  to  his  family.  She  was  an  old  patient  of 
mine,  and  after  her  marriage  she  brought  her  physi- 
cal troubles  to  me,  quite  ignorant  of  the  fact  that  she 
was  worn  out  by  family  friction.  My  efforts  were  de- 
voted chiefly  to  teaching  her  Italian  customs  and  de- 
fending her  husband's  family  to  her.  I  did  not  know 


88  SOCIAL  WORK 

any  too  much  about  it.  I  had  myself  to  learn  the 
subject  which  I  was  set  to  teach,  as  one  does  so  often 
in  social  work.  I  had  to  find  out  the  meaning  of  many 
queer  Italian  customs  in  order  to  interpret  them  to 
her.  At  first  she  had  no  idea  that  when  one  crosses  a 
racial  line  one  must  shift  considerably.  But  she  has 
finally  learned  it,  and  she  is  happy  now. 

I  have  spoken  of  two  social  deficiencies  —  igno- 
rance and  shiftlessness.  I  beUeve  there  are  very  few 
cases  in  the  social  worker's  domain  which  fail  to  show 
some  sort  of  ignorance,  some  sort  of  shiftlessness,  as 
an  element  in  the  social  diagnosis.  Such  diagnoses 
must  usually  be  long.  They  are  complicated  and  can- 
not often  be  expressed  in  one  word.  The  word  "feeble- 
minded" and  the  word  "tramp"  ("Wanderlust")  are 
among  the  rare  examples  of  a  brief  social  diagnosis 
which  explains  all  the  physical,  economical,  moral 
misfortunes  which  one  finds  in  a  person.  But  gener- 
ally one  cannot  find  such  a  phrase.  So  one  makes  a 
number  of  statements  as  one  makes  a  fist  of  many 
diseased  states  ui  the  different  organs  of  the  hu- 
man body.  I  do  not  regret  this.  The  best  medical 
diagnoses,  those  made  after  death,  contain  from 
thirteen  to  seventeen  items  on  the  average.  One  of 
my  chief  tasks  during  the  last  fifteen  years  has  been 
to  study  diagnoses  made  after  death  and  compare 
them  with  those  made  in  hfe.  The  real  diagnosis  as  it 
is  revealed  at  autopsy  contains  on  the  average  thir- 
teen to  seventeen  items.  The  diagnosis  made  during 
life  contains  often  but  two  or  three  items.  This  brev- 


MENTAL  INVESTIGATION  89 

ity  is  characteristic  of  the  very  partial  truth  con- 
tained in  our  cHnical  diagnoses.  Therefore  I  do  not 
altogether  regret  it  when  I  see  in  a  social  diagnosis  a 
long  series  of  items  referring  one  after  another  to  the 
main  departments  of  human  life.  When  we  are  mak- 
ing our  medical  diagnoses  we  try  to  say  what  is 
wrong  with  the  heart,  the  arteries,  the  kidneys,  the 
stomach,  etc.,  in  each  patient.  So  in  making  our  so- 
cial diagnoses  we  ought  to  go  through  some  such  list 
as  I  have  begun  to  give  here.  Is  ignorance  a  factor?  If 
so,  where?  Is  shiftlessness  in  this  particular  case  a 
factor,  and  how?  There  are  certain  organs  of  the  hu- 
man soul  which  one  can  go  through  and  check  up. 
(Anything  the  matter  here?  Anything  the  matter 
there?)  as  one  goes  through  the  bodily  organs  to 
make  a  medical  diagnosis. 

Instability 

The  shiftless  person,  in  the  sense  in  which  I  de- 
fine the  words,  is  the  person  who  does  not  move  often 
enough,  who  rests  too  long  on  one  particular  set  of 
habits  so  that  he  allows  the  world  to  move  away 
from  him  while  he  is  left  high  and  dry.  Or  he  allows 
himself  to  get  fixed  in  one  httle  set  of  habits  and 
becomes  a  person  with  one  idea.  That  is  shiftless- 
ness, the  person  who  cannot  accommodate  or  adapt 
himself. 

The  opposite  of  this  is  instability  —  the  defect  of 
the  person  who  shifts  too  often,  who  cannot  stay  in 
one  field  long  enough.  In  the  physical  field  this  ap- 


90  SOCIAL  WORK 

plies  to  people  with  motor  nervousness,  people  who 
never  can  keep  still.  But  we  are  more  interested,  of 
course,  in  the  psychical  side  of  it.  Any  piece  of  work 
can  be  said  to  have  three  phases,  something  like  the 
phases  that  Sir  Almoth  Wright  has  emphasized  in 
his  writings  on  immunity.  We  have  first  a  stage  of 
interest  and  elation,  then  a  slump,  a  depressed  or 
negative  phase,  as  Wright  said,  a  stage  when  things 
are  not  going  smoothly  or  when  organization  seems 
endlessly  complicated.  Then  is  the  time  when,  if  we 
are  of  an  unstable  type,  we  throw  up  our  work.  The 
unstable  person  cannot  beheve  that  the  imdertal^ing 
is  going  on  and  up  to  a  third  or  positive  phase,  which 
in  the  end  will  be  on  a  higher  level  than  the  phase  in 
which  we  started.  Normal  people  habitually  expect 
these  three  phases  in  every  human  undertaking. 
They  foresee  the  negative  phase  before  they  get  out 
of  the  first  one.  Hence  they  are  not  astounded  or  bit- 
ter when  the  inevitable  slump  comes  in  the  second 
phase.  But  the  unstable  person  breaks  off  at  that 
point  and  tries  something  else.  It  constitutes  one  of 
the  most  serious  blots  in  any  one's  record  if  we  fmd 
that  he  has  changed  his  work  four  or  five  times  al- 
ready. "Why  did  you  leave  your  first  job?"  we  ask, 
and,  "Why  did  you  leave  the  second  one?"  There  is 
never  a  satisfactory  reason  for  so  many  changes. 
These  people  are  rolling  stones;  they  gather  no 
moss.  They  never  accumulate  skill,  power,  and 
money  as  the  result  of  having  stuck  long  enough  in 
one  place. 


MENTAL  INVESTIGATION  91 

We  see  mental  instability  also  in  temperament,  in 
spirits.  Many  people  get  into  trouble  because  they 
do  not  realize  their  own  "negative"  and  "positive" 
phases.  Most  people,  we  say,  have  their  ups  and 
downs.  But  if  we  take  our  ups  and  downs  too  seri- 
ously, then  we  may  talk  about  suicide  as  so  many 
people  do.  It  is  in  these  emotionally  unstable  phases 
that  people  give  offence  to  others,  quarrel  with  their 
famihes,  lose  their  jobs. 

Instabihty  is  much  less  important  in  the  adoles- 
cent stage.  Many  a  parent  has  been  in  despair  over 
his  adolescent  children.  "Nothing  good  ever  can 
come  out  of  that  boy.  He  is  too  unstable,"  the  parent 
is  apt  to  say.  Yet  great  good  often  does  come  out  of 
such  a  boy,  simply  because  he  grows  older.  Such  a 
boy  is  generally  between  thirteen  and  nineteen.  Tre- 
mendous physical  changes  are  going  on,  which  are 
rather  more  than  he  can  manage.  Hence  he  becomes 
for  a  time  unreliable,  capricious,  moody.  There  is  al- 
most no  degree  of  mental  instabihty  and  unsatisfac- 
tory conduct  which  may  not  wholly  disappear  as 
we  get  past  the  adolescent  stage. 

On  the  other  hand,  the  older  a  person  is  the  more 
serious  the  outlook  in  a  case  of  instabihty.  A  woman 
in  the  vicinity  of  sixty  drifted  into  my  hands  some 
years  ago,  after  having  been  the  round  of  doctors 
whose  diagnosis  was  essentially  instability.  Although 
I  labored  very  long  and  prayerfully  with  that  indi- 
vidual, I  cannot  say  that  I  produced  any  consider- 
able effect. 


92  SOCIAL  WORK 

Remember  always  the  possibility  that  such  in- 
stabihty  is  due  to  drugs.  Among  the  most  unstable 
people  are  the  morphine-takers,  and  because  that 
has  among  other  symptoms  concealment  and  lying, 
it  does  not  easily  come  to  Ught.  In  the  evening  the 
morphine-taker  is  full  of  prowess,  is  full  of  hope, 
ready  to  make  engagements  for  nine  o'clock  the  next 
morning.  But  he  ahnost  never  turns  up  for  that  en- 
gagement the  next  morning.  This  morning  depres- 
sion is  common  also  in  many  other  diseases,  such  as 
neurasthenia  and  that  rare  disease,  anemia.  The 
anemic  patient  has  a  hard  time  getting  up  in  the 
morning,  but  it  is  the  fault  of  his  red  corpuscles  and 
not  of  his  character. 

Another  phase  of  instabiUty  is  abnormal  suggesti- 
bility, abnormal  6penness  to  influence  or  "sugges- 
tion" in  the  psychological  sense.  I  cannot  count  the 
number  of  fond  but  foohsh  mothers  who  have  said 
to  me  about  a  child,  "John  is  a  good  boy,  only  he  is 
weak.  He  gets  led  astray  by  his  companions." 
Everybody  is  and  ought  to  be  somewhat  suggestible, 
normally  suggestible.  The  man  v/ho  is  not  suggesti- 
ble is  the  person  with  a  monomania,  who  can  see 
nothing  but  his  own  view,  is  stupidly  attached  to 
one  set  of  ideas  and  so  cannot  learn.  But  one  can 
easily  be  too  suggestible.  Over-suggestible  people 
run  after  every  craze,  are  impressed  with  each  new 
rehgion,  or  are  tremendously  excited  with  each  new 
friend  and  think  of  each  new  experience:  "Ah!  This 
is  what  I  have  been  looking  for  all  my  hfe.  Nothing 


MENTAL  INVESTIGATION  93 

else  matters."  This  is  especially  common  at  the  ado- 
lescent age,  but  it  is  a  danger  for  all  of  us,  men  and 
women  of  every  age.  We  get  carried  away  by  popu- 
lar crazes,  by  influences,  by  suggestions,  so  that  we 
cannot  remember  the  good  that  there  was  in  our 
previous  beliefs  and  interests.  If  so  we  are  men- 
tally unstable  in  this  respect. 

We  see  in  every  dispensary  many  cases  of  abnor- 
mal physical  suggestibihty,  people  who  think  that 
they  have  caught  every  disease  that  they  hear  about. 
Among  medical  students  and  nurses  in  training 
there  are  always  some  who  become  convinced  that 
they  have  the  disease  which  they  have  just  been 
studying  in  the  hospital.  In  the  social  assistant's 
work  as  a  taker  of  histories  she  must  remember  that. 
Highly  suggestible  people  give  curiously  misleading 
histories  because  they  become  obsessed  with  the 
idea  that  they  have  some  terrible  disease.  There  are 
three  examples  of  abnormal  suggestibility  which  in 
my  experience  recur  with  especial  frequency:  heart 
disease,  cancer,  insanity.  People  are  amazingly  prone 
to  fancy  that  they  have  heart  disease.  If  they  have 
any  symptoms  in  that  part  of  the  body  where  they 
are  taught  to  believe  that  the  heart  resides,  or  if 
they  have  heard  anybody  talk  of  heart  disease,  or 
especially  if  anybody  whom  they  know  has  re- 
cently died  of  heart  disease,  there  are  many  people 
likely  first  to  believe  that  they  have  heart  trouble, 
and  then  to  have  actual  symptoms  which  they  at- 
tribute to  heart  disease.  They  often  say  nothing 


94  SOCIAL  WORK 

about  this  fear.  That  is  just  why  it  is  so  essential  for 
social  workers  to  dig  it  out  in  the  course  of  their 
history-taking.  When  people  are  afraid  of  a  thing 
they  are  especially  apt  to  conceal  that  fear. 

Insanity  is  feared,  I  think,  even  more  often  than 
heart  disease.  Every  doctor  is  consulted  by  people 
who  are  sure  on  most  trifling  evidence  that  they  are 
going  insane.  We  hear  people  say,  "Why  my  mind 
must  be  failing,  for  I  read  down  a  page  and  when  I 
get  to  the  bottom  I  cannot  remember  what  I  have 
read."  Or,  "  I  am  losing  all  memory.  I  met  a  man  re- 
cently suddenly  and  I  could  not  remember  his 
name."  These  two  normal  fatigue-products  —  fail- 
ure of  attention  or  failure  of  memory  —  often  make 
people  think  that  they  are  going  insane.  A  third  re- 
sult of  fatigue  which  often  frightens  people  is  the 
sense  of  unreahty.  Such  people  say,  "  I  seem  to  be 
numb.  Things  do  not  seem  real  to  me.  I  talk  to  peo- 
ple and  I  wonder  if  it  is  not  all  a  dream.  Am  I  not 
going  crazy?"  There  have  been  interesting  essays 
written  by  French  psychologists  on  the  "Sense  of 
the  Deja  Vu."  For  a  few  hours  whatever  we  say  or 
do  seems  a  repetition;  we  have  said,  done,  heard  all 
that  before  we  fancy.  It  is  a  very  disquieting  sense. 
But  it  is  usually  nothing  but  fatigue. 

Cancer  I  suppose  is  the  most  dreaded  of  all  dis- 
eases, but  one  of  the  most  unnecessarily  feared.  Pa- 
tients may  appear  at  the  dispensary  for  most  trifling 
pains  or  stomach  troubles,  troubles  that  all  of  us 
would  disregard,  and  when  we  inquire  why  it  is  that 


MENTAL  INVESTIGATION  95 

they  have  come,  sometimes  a  long  distance  and  at 
considerable  expense,  we  find  out  that  it  is  because 
they  have  recently  heard  or  read  something  about 
cancer,  or  remembered  that  there  is  cancer  in  the 
family.  We  cannot  be  too  careful  to  tell  people  that 
cancer  is  not  hereditary.  People  are  apt  to  think  it 
hereditary,  but  this  is  one  of  the  medical  fallacies 
that  we  should  all  of  us  do  our  part  to  eradicate 
from  the  public  mind. 

I  will  mention  one  or  two  other  common  ground- 
less physical  fears.  We  should  teach  people  that  if 
they  have  a  pain  in  the  left  side  of  the  chest  the 
chances  are  about  nine  out  of  ten  that  the  heart  is 
perfectly  sound.  If  they  have  a  pain,  as  they  say, 
** across  the  kidneys,"  the  chances  are  ninety-nine 
out  of  one  hundred  that  the  kidneys  are  perfectly 
healthy.  The  newspaper  advertisements  of  charla- 
tans do  all  they  can  to  make  people  think  that  a 
pain  in  the  back  must  be  kidney  trouble.  We  must 
fight  such  poisonous  influences. 


CHAPTER  V 

MENTAL  INVESTIGATION  BY  THE  SOCIAL  ASSISTANT 
(^continued) 

Fears  and  forgetfulness 

It  is  not  merely  because  of  a  doctor's  mental  habit 
that  I  speak  of  life  in  terms  of  diagnosis  and  treat- 
ment. For  though  those  particular  words  are  medi- 
cal, any  part  of  Ufe  can  be  thus  conveniently  summed 
up.  One  tries  to  find  out  the  facts  about  some  region 
of  life  in  which  one  works  or  plays,  fights,  loves,  or 
worships  (diagnosis),  and  then  one  tries  to  do  some- 
thing about  it  (treatment).  If  one  makes  a  friend 
one  tries  to  find  out  something  about  him  and  then 
to  treat  him  accordingly.  If  one  comes  to  a  new  city 
one  tries  to  diagnose  its  geography  and  to  direct 
one's  self  accordingly.  If  there  is  anything  not  in- 
cluded in  that  set  of  phrases  about  the  behavior  of 
the  human  being  towards  the  world,  I  do  not  know 
it.  Therefore  it  seems  natural  to  sum  up  social  work 
also  in  terms  of  diagnosis  and  treatment. 

I  referred  in  the  last  chapter  to  social  ignorance  as  a 
possible  item  in  a  social  diagnosis.  I  meant  to  recall 
those  parts  of  a  person's  outfit  for  dealing  with  life  in 
which  he  is  deficient  because  of  ignorance,  industrial 
ignorance,  or  educational  ignorance,  or  physical  ignor- 
ance. I  went  on  to  recall  two  other  mental  deficiencies 
or  sources  of  incapacity,  shiftlessness  and  instability. 


MENTAL  INVESTIGATION  97 

In  this  chapter  I  want  to  exempHfy  fears  as 
sources  of  inefficiency  or  deficiency,  as  causes  of  sick- 
ness, economic  dependence,  and  unhappiness.  Chris- 
tian Scientists  define  ahnost  all  human  ills  in  terms 
of  fear.  That  is  extreme.  I  know  many  people  who  do 
not  seem  to  suffer  from  any  fears  whatever.  I  some- 
times wish  they  suffered  from  a  few  more.  I  should 
not  say  at  all  that  fears  were  the  cause  of  all  evil,  or 
that  the  fearless  person  was  perfect.  Still,  fear  is  a 
very  great  factor  in  social  ills.  I  mentioned  in  the  last 
chapter  the  three  commonest  physical  fears  as  met 
with  in  medical  practice:  fears  about  the  heart, 
about  cancer,  and  about  insanity.  I  sometimes  feel 
that  I  will  never  let  a  patient  go  from  me  without 
saying,  "You  have  not  got  heart  disease,  you  have 
not  got  cancer,  you  are  not  going  insane,"  even  if  he 
came  to  me  for  a  cut  finger  or  an  ingrowing  toe-nail. 
No  one  but  a  physician  can  appreciate  how  many 
people  dread  one  of  these  three  diseases. 

But  about  physical  fears  as  about  other  fears,  the 
most  important  thing  to  know  is  that  they  are  dis- 
abling, crippling,  in  proportion  as  they  are  not  rec- 
ognized, or  only  semi-conscious.  I  am  one  of  those 
who  believe  that  one  should  not  talk  about  uncon- 
scious consciousness,  although  synonymous  phrases 
are  very  popular  among  modern  psychologists.  But 
we  all  of  us  know  that  a  large  part  of  our  mental  life 
is  in  a  half  light,  neither  in  full  consciousness  nor  in 
oblivion.  These  half  lights  may  be  quite  harmless, 
but  often  they  are  especially  mischievous.   Our 


98  SOCIAL  WORK 

vague,  undefined  experiences  produce  the  fears 
which  trouble  us  most.  Fear  of  the  dark  and  fear  of 
ghosts  exemphfy  this  rule,  but  it  holds  just  as  well 
for  fears  about  disease. 

Partly  because  of  this  vagueness,  people  often  do 
not  tell  the  doctor  about  their  most  serious  fears. 
One  has  to  go  out  of  one's  way  to  reassure  people 
about  their  fears,  because  they  so  often  conceal 
them.  Of  course  there  are  exceptions  to  that.  People 
come  to  a  doctor  often  for  nothing  else  except  fears. 
But  that  is  not  true  of  the  majority  of  patients  nor 
of  those  suffering  the  most  harmful  and  haunting 
fears.  It  is  for  that  reason  that  I  am  trying  to  give 
some  idea  of  where  to  look  for  facts  that  do  not  come 
spontaneously  to  you  as  patients  tell  their  stories.  If 
the  social  assistant  has  not  the  medical  knowledge  or 
the  authority  necessary  to  reassure  the  patient,  she 
can  bring  him  to  somebody  who  has.  At  the  present 
time  there  is  no  piece  of  medical  service  more  clean- 
cut  and  satisfactory  than  the  power  to  reassure  a 
person  about  an  illness  that  he  thinks  he  has,  half- 
consciously  fears  he  has,  and  therefore  tries  to  ban- 
ish from  his  mind.  To  discover  groundless  fears, 
then,  fears  of  poverty,  of  ridicule,  of  marital  unhap- 
piness,  and  to  cure  them  by  bringing  them  to  light,  is 
the  task  that  I  think  every  social  worker  should  con- 
sider as  part  of  her  job,  in  so  far  as  she  is  connected 
with  medical  work,  as  she  must  be  always  so  far  as 
I  see. 

It  is  astonishing  how  often  people  are  reheved  by 


MENTAL  INVESTIGATION  99 

knowing  a  truth  which  we  shrink  from  imparting.  I 
recently  examined  at  a  Red  Cross  Dispensary  in 
Paris  an  old  lady  in  face  of  whose  troubles  I  was  a 
httle  daunted  when  I  came  to  carrying  out  the  prin- 
ciple of  telling  the  truth  as  I  have  long  preached  and 
tried  to  practise  it.  She  had  a  chronic  asthma.  She 
suffered  a  good  deal  from  it  both  night  and  day,  and 
I  could  not  see  the  sUghtest  prospect  that  she  would 
ever  be  any  better,  because  in  people  past  middle  life 
asthma  is  for  all  intents  and  purposes  an  incurable 
disease.  When  I  had  finished  examining  this  old  lady 
and  faced  my  task  of  telhng  her  the  truth,  I  did  not 
feel  comfortable  about  it  at  all.  But  I  gave  her  the 
facts.  The  outcome  was  striking.  "Oh,  yes,"  she  said, 
**  I  rather  thought  that  my  asthma  is  incurable.  I  did 
not  expect  that  you  could  do  anything  to  cure  it.  All 
I  wanted  was  to  make  sure  that  I  had  not  got  tuber- 
culosis on  top  of  it."  About  this  fear  of  tuberculo- 
sis she  had  said  not  a  word  to  the  history-taker.  It 
came  to  light  quite  unexpectedly.  But  when  I  as- 
sured her  that  she  had  not  got  tuberculosis  on  top 
of  her  asthma,  she  seemed  quite  contented  and 
hobbled  away  very  happily,  puffing  and  blowing  as 
she  went. 

That  illustrates  the  refief  that  comes  to  people 
from  finding  that  a  deeper-concealed  fear  is  ground- 
less. Again  and  again  I  have  pushed  myself  up  to 
the  task  of  telling  people  what  I  knew  they  had  to 
know,  and  then  found  that  instead  of  prostrating 
them  I  had  reheved  them  of  torturing  imcertainty. 


100  SOCIAL  WORK 

I  will  relate  an  experience  which  shows  how  far 
this  truth  extends.  An  elderly  lady,  whom  I  had 
known  for  nearly  twenty-five  years  at  the  time  this 
incident  happened,  was  in  the  habit  each  spring  of 
coming  from  New  York,  where  she  hved,  to  Boston, 
where  she  used  to  hve,  to  make  a  round  of  visits 
among  her  friends.  While  still  on  one  of  these  visits 
she  telephoned  me  one  day  to  come  and  see  her.  As  I 
entered  the  house  where  she  was  staying,  I  was  met, 
as  I  have  been  met  so  many  times,  by  a  member  of 
the  household,  who,  with  finger  on  lip  and  every 
precaution  for  silence,  beckoned  me  into  a  side  room 
and  proceeded  to  tell  me  "what  nobody  else  must 
know."  It  was  something  like  this:  That  my  friend 
the  old  lady  had  begun  the  first  of  her  round  of  visits 
about  a  month  before  this.  On  that  first  visit  it  had 
become  pretty  obvious  to  her  friends  that  she  was 
mentally  queer.  She  was  not  a  millionaire,  yet  she 
was  spending  and  giving  away  an  extraordinary 
amount  of  money.  She  was  ordinarily  a  person  of 
quiet  habits  and  not  prone  to  hurry  about,  but  now 
she  was  making  the  dust  fly  all  the  time.  She  was 
ordinarily  modest.  She  had  now  become  boastful. 
The  first  friend  with  whom  she  stayed  believed,  as 
people  usually  do,  that  it  would  be  dangerous  to  tell 
her  anything  about  her  mental  condition,  yet  found 
it  impossible  to  keep  her  in  the  house.  Therefore  the 
hostess  made  the  excuse  that  she  had  a  maid  leaving 
and  could  not  really  keep  a  visitor  just  now.  Would 
my  friend  mind  moving  on  to  the  next  visit?  She 


MENTAL  INVESTIGATION         101 

moved  on  to  Number  Two;  naturally  the  same  thing 
happened  there.  So  the  second  hostess  passed  her 
along  to  Number  Three.  She  was  with  Number  Four 
at  the  time  when  she  called  me. 

All  this  was  given  me  in  the  strictest  secrecy  in 
the  little  anteroom  close  to  the  front  door.  My  in- 
formant then  tried  to  pledge  me  not  to  tell  the  old 
lady  the  truth,  fearing  an  outbreak  of  violence.  But 
as  I  had  a  good  while  ago  sworn  off  all  forms  of 
lying,  I  refused  to  make  any  such  promise. 

I  went  upstairs  to  see  the  patient.  She  poured  out 
to  me  one  of  the  most  pitiful  stories  I  ever  heard  — 
the  same  story  just  given,  but  from  her  own  point  of 
view.  So  far  as  she  could  see,  her  friends  were  all 
playing  her  false  in  some  way,  or  losing  their  affec- 
tion for  her.  She  knew  that  it  was  not  by  accident 
that  one  friend  after  another  had  poUtely  shown  her 
the  door.  Something  was  being  concealed  from  her. 
What  could  it  be?  She  was  really  worn  out,  she  said 
with  worry  and  sorrow  about  it. 

I  told  her  at  once  the  whole  truth.  I  told  her  that 
she  was  insane.  I  could  also  tell  her  truthfully  that 
she  would  come  out  of  it  (as  she  did),  but  that  I 
must  now  take  her  away  from  this  house,  shut  her 
up,  and  take  care  of  her.  "Oh,"  she  said,  with  im- 
mense rehef  in  her  voice,  "is  that  all?  Is  it  nothing 
worse  than  that?  Insanity  is  nothing  compared  to 
losing  all  your  friends."  Insanity  is  one  of  the  great- 
est of  human  fears,  but  for  this  old  lady,  as  for  most 
of  us,  there  is  something  still  worse  —  the  fear  that 


102  SOCIAL  WORK 

one  has  not  a  friend  in  the  world.  Even  to  know  that 
she  was  doomed  to  what  most  people  would  consider 
one  of  the  worst  of  fates  was  to  her  a  rehef ;  for  there 
was  a  worse  fear  in  reserve,  and  that  she  now  knew 
was  groundless. 

The  treatment  of  fears,  the  only  treatment  that  I 
know  of,  is  that  we  face  them,  look  straight  at  them, 
as  we  turn  a  skittish  horse's  head  right  towards  the 
thing  that  he  is  going  to  shy  at,  so  he  can  look  at  it 
squarely.  So  we  try  to  turn  the  person's  mental  gaze 
straight  upon  the  thing  that  he  fears. 

People  frequently  consult  a  doctor  because  they 
are  afraid  of  fainting,  fainting  in  church  or  in  the 
street,  for  example.  In  such  cases  I  have  found  it 
most  effective  to  say,  "Well,  suppose  you  do  — what 
harm  will  it  do?"  From  the  answers  to  this  question 
I  find  generally  that  the  patients  have  in  the  back  of 
their  minds,  unconfessed,  unrealized,  the  fear  that 
if  they  faint  and  nothing  adequate  is  done  to  cure 
them  they  will  die.  They  do  not  know  that  people  who 
faint  come  to  just  as  well  if  they  are  let  alone,  and 
that  all  the  fussing  about  that  is  usual  when  people 
faint  is  useful  merely  to  keep  the  bystanders  busy 
and  not  to  revive  the  patient. 

Make  a  person  face  "the  worst"  and  you  disarm 
its  terrors. 

"But  suppose  I  get  faint  on  the  street?" 

"Well,  you  probably  will  just  sit  down  on  the 
curbstone  until  you  come  to." 


MENTAL  INVESTIGATION         103 

That  remark  does  not  sound  as  if  it  would  reas- 
sure a  person  even  if  made  with  a  laugh.  But  it  does, 
because  he  is  thereby  freed  of  a  fear  of  something 
much  worse,  a  fear  that  lurks  in  the  background  of 
his  mind. 

There  is  one  other  thing  to  be  said  about  the  treat- 
ment of  fears.  If  a  person  fears  to  do  any  particular 
act,  such  as  going  to  church  or  into  the  subway,  if  he 
fears  to  be  alone  in  crossing  a  big  square,  if  he  fears  to 
get  into  a  crowd  (all  these  are  common  fears),  the 
most  important  thing  is  to  force  him  to  do  what  he 
most  fears. 

"Do  the  thing  you  are  afraid  of,  or  soon  you  will 
be  afraid  of  something  else  as  well.  And  the  more 
you  do  what  you  fear  to  do,  the  less  you  will  be 
afraid  of  it,  because  your  act  will  bring  you  evidence 
of  the  truth.  Your  act  will  prove  to  you  that  you  can 
do  the  thing  that  you  fear  you  cannot.  That  fact 
will  convince  you  a  great  deal  more  than  all  the  talk- 
ing that  your  doctor  or  anybody  else  can  do.  You 
will  get  conviction  by  reahty,  the  best  of  all  wit- 
nesses." 

Among  the  poor,  with  whom  we  deal  part  of  the 
time  in  social  work  —  though  I  insist  that  social 
work  is  concerned  with  the  rich  as  well  —  we  have 
to  face  economic  fears.  In  America  and  England  eco- 
nomic fears  are  a  very  real  evil  — fears  of  the  work- 
house, fears  of  coming  to  be  dependent,  of  having 
no  place  of  their  own,  are  what  poor  people  often 
dread.  Again,  the  clue  for  our  usefulness  is  to  fmd 


104  SOCIAL  WORK 

out  what  people  do  not  tell  us  of  these  economic 
fears,  and  then  to  see  if  we  can  make  them  ground- 
less. 

In  a  certain  number  of  people  (I  do  not  feel  com- 
petent to  say  how  large  a  portion),  life  is  rendered 
miserable  by  the  fear  of  being  found  out.  I  hap- 
pened, as  I  have  already  said,  to  get  driven  some 
years  ago  into  a  position  where  I  thought  it  best  to 
swear  off  medical  lying.  One  of  the  surprising  parts 
of  this  experience  was  the  sense  of  relief  which  I  felt 
when  I  knew  that  there  was  no  longer  anything  in 
my  medical  work  that  I  was  afraid  of  having  any 
one  find  out.  It  was  in  benevolent,  unselfish  medical 
lies  that  I  had  been  dealing,  according  to  the  ordi- 
nary practice  of  the  medical  profession.  But  as  soon 
as  I  decided  that  I  could  abandon  these  and  need  no 
longer  fear  that  any  patient  might  find  out  what 
was  being  done  to  him,  I  had  the  sense  of  a  weight 
taken  off  my  shoulders. 

Forgetfulness 

There  is  a  very  eloquent  passage  in  one  of  Mrs. 
Bernard  Bosanquet's  books  ^  about  social  work,  in 
which  she  describes  the  psychology  of  the  poorer 
classes  among  whom  she  worked  in  London,  and 
dwells  especially  on  their  characteristic  forgetful- 
ness. They  cannot  learn  because  they  cannot  re- 
member. They  cannot  learn  how  to  avoid  mistakes 

^  Bosanquet,  Helen.  The  Standard  of  Life  and  Other  Studies.  (Lon- 
don, Macmillan  &  Co.,  1898.)  The  Family.  (London,  Macmillan  & 
Co.,  1906.) 


MENTAL  INVESTIGATION         105 

in  future  because  they  cannot  remember  past  mis- 
takes. One  well-known  difference  between  a  feeble- 
minded person  and  a  person  competent  to  manage 
the  affairs  of  life,  is  that  the  former  forgets  so  ex- 
traordinarily, and  therefore  cannot  build  up  through 
remembrance  of  his  past  how  to  steer  better  through 
the  future.  Of  course  we  all  of  us  have  this  disease 
in  varying  degrees.  We  all  forget,  in  the  moral  field 
as  well  as  the  physical,  things  that  we  ought  to  re- 
member. There  are  things  that  we  ought  to  forget. 
After  we  have  started  to  jump  a  fence,  we  must  not 
remember  the  possibility  of  our  failing.  The  time  to 
remember  that  is  before  we  have  begun  to  jump. 
Moreover,  there  is  no  particular  benefit  in  remem- 
bering our  own  past  mistakes  if  they  are  such  that 
we  cannot  do  anything  about  them,  morally  or  any 
other  way. 

There  are  things,  then,  that  we  ought  to  forget, 
but  allowing  for  these,  forgetfulness  means  forget- 
ting the  things  which  we  ought  to  remember.  In  al- 
coholism it  is  extraordinary  how  much  the  person 
forgets.  One  cannot  fail  to  be  struck  by  the  fact  that 
the  alcohoUc  gets  into  trouble  again  and  again  be- 
cause he  cannot  fully  remember  what  happened  be- 
fore. In  the  field  of  sex  faults  this  truth  is  equally 
obvious.  A  man  is  unfaithful  to  his  wife  because  he 
allows  himself  to  forget  his  wife  —  his  memory  of 
her  is  for  the  moment  blotted  out.  Nobody  could 
violate  his  own  standards  in  this  field  if  he  could 
vividly  remember  them.  Hence  if  we  are  to  help  any 


106  SOCIAL  WORK 

one  else  to  govern  himself  in  matters  of  affection  we 
must  help  him  to  remember,  help  him  by  planning 
devices  that  make  it  nearly  impossible  to  forget. 

Bad  temper  can  ordinarily  be  explained  by  forget- 
fulness.  We  can  hardly  lose  our  temper  with  a  person 
if  we  remember  the  other  sides  of  his  nature  opposed 
to  that  with  which  we  are  just  now  about  to  quarrel. 
Nobody  consists  wholly  of  irritating  characteristics. 
We  all  possess  them;  but  we  all  possess  something 
else  besides.  Hence  if  we  can  realize  some  of  our  own 
moments  of  wrath,  I  think  we  must  confess  that  for 
the  moment  the  person  with  whom  we  were  enraged 
possessed  for  us  but  a  single  characteristic.  The  rest 
were  forgotten. 

My  account  of  these  five  common  types  of  mental 
deficiency:  ignorance,  shiftlessness,  instability,  fears, 
forgetfulness,  is  general  and  vague.  I  mean  to  make 
it  so.  If  my  suggestions  are  of  any  use  to  the  reader 
it  will  be  because  he  is  able  to  make  his  own  spe- 
cific apphcations.  I  want,  however,  to  mention  one 
example  of  a  much  more  specific  fault,  namely,  nag- 
ging. In  social  work  we  often  see  famihes  broken  up 
or  seriously  cracked  by  some  one's  nagging.  It  con- 
sists in  reminding  people  of  their  defects  and  short- 
comings in  season  and  out  of  season,  until  the  re- 
minder finally  gets  upon  their  nerves.  You  are  aware 
that  your  husband,  your  wife,  your  child,  has  some 
very  deleterious  fault.  Admittedly  he  has  it  and  it  is 
constantly  getting  him  into  trouble.  So  you  want  to 


MENTAL  INVESTIGATION         107 

be  quite  sure  that  it  never  gets  him  into  trouble 
again;  and  hence  you  keep  reminding  him  of  it  again 
and  again  until  you  produce  an  irritation  that  only 
aggravates  the  original  fault. 

Why  do  I  take  so  trivial  and  specific  a  case  as  this? 
Because  I  can  remember  several  cases  where  I  could 
not  possibly  leave  out  nagging  when  I  came  to  make 
my  social  diagnosis.  It  was  one  of  the  chief  factors. 
One  cures  this  disease,  in  case  one  does  help  it  at  all, 
by  making  the  nagging  person  conscious  of  what  it  is 
that  he  is  doing.  The  nagging  impulse  is  hke  an  itch. 
It  recurs  and  scratching  does  not  stop  it.  The  nagger 
does  not  know  quite  why  he  does  it;  he  finds  himself 
doing  it  ahnost  in  his  sleep.  Hence  we  try  to  wake 
him  up,  to  make  him  conscious,  if  we  can,  of  his  fool- 
ishness, of  the  kind  of  harm  he  is  doing,  and  of  the 
degree  of  incurability  he  is  inducing  in  the  person 
whom  he  is  trying  to  cure. 

I  will  now  sum  up  the  last  four  chapters  in  a  dia- 
gram which  we  have  used  in  Boston  at  the  Massa- 
chusetts General  Hospital  to  assist  us  in  making  our 
social  diagnoses.  A  social  diagnosis  can  very  seldom 
be  made  in  one  word,  such  as  idiocy  or  tramp.  It 
must  include  the  patient's  physical  state.  It  must 
summarize  a  person's  physical,  moral,  and  economic 
needs.  Our  best  social  diagnoses,  such  as  idiocy  or 
feeble-mindedness,  do  not  refer  to  the  mind  only. 
They  refer  to  the  body  just  as  much.  Feeble- 
mindedness is  a  statement  about  the  child's  body. 


108  SOCIAL  WORK 

his  brain,  his  voracious  appetite,  the  diseases  to 
which  he  is  hkely  to  succumb,  his  extraordinary  sus- 
ceptibihty  to  cold,  and  his  poor  chances  of  growing 
up.  One  says  a  great  deal  about  the  physical  side  of  a 
child  as  soon  as  one  pronounces  the  word  "feeble- 
minded." Also  one  says  a  great  deal  about  his  finan- 
cial future.  One  knows  that  the  feeble-minded  child 
will  never  rise  beyond  a  very  low  point  in  the  eco- 
nomic scale.  One  says  also  a  great  deal  about  his 
moral  future.  We  all  know  to  what  sexual  dangers 
and  temptations  he  is  especially  exposed.  And  on 
the  purely  psychological  side  one  can  predict  his  en- 
tire unteachability  beyond  a  perfectly  definite  limit. 
All  this  is  given  in  the  medical-social  diagnosis, 
"  feeble-mindedness." 

This  is  an  example,  then,  of  an  ideally  complete 
and  compact,  though  a  very  sad,  social  diagnosis.  It 
is  almost  the  only  good  one  we  have  worked  out  as 
yet.  The  only  other  is  "tramp."  The  tramp  in  a  tech- 
nical sense  is  a  person  who  has  what  the  Germans 
call  "Wanderlust."  He  is  unable  to  stay  in  one  place. 
Perpetually  or  periodically  he  desires  to  move  and  to 
keep  moving.  The  tramp  is  a  medical-social  entity. 
He  has  certain  physical  limitations,  certain  eco- 
nomic limitations,  certain  moral  deficiencies.  But  in 
America  he  is  rather  a  rare  being.  One  does  not  see 
many  typical  tramps  here. 

Since  few  social  (or  medical-social)  diagnoses  can 
be  stated  in  a  single  word,  one  is  usually  forced  to 
write  down  one's  diagnosis  in  a  great  many  different 


MENTAL  INVESTIGATION 


109 


items.  As  a  guide  I  made  four  years  ago  a  schedule 
for  our  use  at  the  Massachusetts  General  Hospital. 
Use  —  the  only  test  for  that  sort  of  thing  —  has 
shown  this  schedule  to  be  of  some  value. 


Diagnosis 
shall  , 

characterize 


I.  The  Individual 


1.  Physical 

2.  Mental  ■< 


a.  Heredity. 

b.  Health. 

a.  Mental  defi- 

ciency. 

b.  Mental  disease. 

c.  Tempereiment. 

Character. 


II.  HisEiivironment- 


a.  Food.     Clothes. 
Housing. 

b.  Industrial    con- 
ditions. 

'I.  Physical -{c.  School   condi- 
tions. 
d.  Climate.  Natu- 
ral beauty  or 
ugliness, 
'a.  Family      and 
friends. 
2.  Mental  ■<  b.  Education. 
Play. 

c.  ReUgion. 

To  make  a  social  diagnosis  we  should  make  a  sum- 
mary statement  about  the  individual  in  his  environ- 
ment. That  summary  is  to  include  his  mental  and 
physical  state,  and  the  physical  and  mental  charac- 
teristics of  his  environment.  (I  here  use  the  word 
"mental"  to  include  everything  that  is  not  physi- 
cal; that  is,  to  include  the  moral,  the  spiritual,  every 
influence  that  does  not  come  under  physics  or  chem- 
istry.) 

When  the  investigation  of  a  patient  is  divided  be- 
tween doctor  and  social  worker,  the  doctor  studies 
his  physique;  the  social  worker  studies  the  rest.  I  be- 


no  SOCIAL  WORK 

lieve  that  there  is  nothing  that  we  can  want  to  know 
about  any  human  being,  rich  or  poor,  that  is  not 
suggested  in  that  schedule.  Suppose,  reader,  that  a 
friend  of  yours  was  engaged  to  be  married.  Suppose 
you  wanted  to  know  something  about  the  fiance. 
You  would  certainly  want  to  know  about  his  health 
and  his  heredity;  then  w^hat  sort  of  a  person  he  was, 
his  mentahty,  whether  he  had  any  money  —  what 
are  the  obvious  physical  facts  about  his  environ- 
ment. To  what  influences  has  he  been  subjected,  and 
what  mental  supports,  such  as  education  and  recrea- 
tion, family,  friends,  and  religion,  can  he  count  upon? 
You  would  not  want  to  know  any  more  and  you 
ought  not  to  want  to  know  any  less. 

So  in  summing  up  a  social  diagnosis  I  think  it  is 
convenient  to  use  the  four  main  heads  that  I  have 
put  down  here.  I  think  these  headings  will  remind  us 
of  everything  that  we  w^ant  to  put  down,  and  of 
everything  that  we  may  have  forgotten  to  look  up. 
That  is  one  function  of  such  a  schedule  —  to  remind 
us  of  the  things  which  we  have  forgotten. 

Made  up  in  such  a  way  as  this,  of  course  the  social 
diagnosis  will  have  many  items,  and  like  medical 
diagnosis  it  will  be  subject  to  frequent  revisions. 
The  doctor  who  never  changes  his  diagnosis  is  the 
doctor  who  never  makes  one,  or  who  makes  it  so  elas- 
tic that  it  means  nothing.  So  social  workers  should 
never  fear  to  add  to,  to  subtract  from  or  to  modify 
their  social  diagnoses. 

The  best  medical  diagnoses  —  those  made  after 


MENTAL  INVESTIGATION         111 

death  —  often  contain  fifteen  or  twenty  items.  Be- 
fore death  in  a  recent  case  we  found  pneumonia^ 
After  death  we  found  in  addition :  meningitis,  heart- 
valve  disease,  kidney  trouble,  gall-stones,  healed 
tuberculosis,  and  ten  minor  troubles  in  various  parts 
of  the  body. 

So  a  good  social  diagnosis  will  name  many  mis- 
fortunes of  mind,  body,  and  estate,  healed  wounds 
of  the  spirit  that  have  left  their  scar,  ossifications, 
degenerations,  contagious  crazes  which  the  person 
has  caught,  deformities  which  he  has  acquired. 


CHAPTER  VI 

THE  SOCIAL  worker's  INVESTIGATION  OF  FATIGUE, 
REST,  AND  INDUSTRIAL  DISEASE 

Fatigue  and  rest 

Fatigue  is  more  important  for  medical-social  work- 
ers to  understand  than  any  single  matter  in  physiol- 
ogy or  any  aspect  of  the  interworkings  of  the  human 
body  and  soul,  because  it  comes  into  almost  every 
case  from  two  sides :  (a)  from  the  workers'  side  be- 
cause the  quality  of  work  that  she  puts  into  trying  to 
help  somebody  else  depends  on  how  thoroughly  she  is 
rested,  and  how  much  she  has  to  give;  and  {b)  from 
the  side  of  the  patient,  his  physical,  economic,  and 
moral  troubles,  because  fatigue  is  often  at  or  near 
the  root  of  all  these  troubles.  It  is  unfortunate 
that  in  spite  of  its  importance,  we  do  not  know  much 
about  fatigue  from  the  physiological  point  of  view. 
Since  the  war  of  1914-1918  we  have  prospects  of 
knowing  more  about  it  than  ever  before;  for  one  of 
the  grains  of  good  saved  out  of  the  war's  enormous 
evils  has  been  the  fruitful  studies  of  fatigue  made  in 
England,  studies  more  valuable  than  any  that  I 
know  of. 

Let  us  take  fatigue  in  some  of  its  very  simple 
phases,  as  it  appKes  to  your  life  and  mine.  The  first 
thing  to  recognize  is  that  it  can  affect  any  organ;  our 
stomachs  can  get  tired,  just  as  well  as  our  legs. 


FATIGUE  AND  REST  113 

When  a  patient  complains  of  pain,  vertigo,  nausea, 
we  first  ask  ourselves,  "What  disease  has  he  got?" 
That  is  correct.  Disease  must  be  found  if  it  is  there. 
But  the  chances  are  he  has  no  disease,  but  only  a 
tired  stomach,  since  fatigue  easily  and  frequently 
affects  that  organ.  When  the  whole  person  has  been 
strained  by  physical,  moral,  and  especially  by  emo- 
tional work,  he  may  give  out  anywhere.  He  may  give 
out  in  his  weakest  spot,  as  we  say.  That  weak  spot 
is  different  in  different  people.  Therefore  the  study 
must  be  individual.  We  cannot  do  anything  impor- 
tant with  our  own  lives  until  we  learn  how  and  when 
we  get  tired.  It  is  the  same  with  people  whom  we  try 
to  help  in  social  work. 

Fatigue,  then,  may  be  referred  to  any  particular 
spot  in  the  body.  People  often  go  to  an  ocuUst  to  see 
what  is  the  matter  with  their  eyes,  when  there  is 
nothing  in  the  world  the  matter  with  their  eyes:  the 
honest  oculist  tells  them  that  they  are  tired,  and 
that  for  some  reason  unknown  to  him  their  fatigue 
expresses  itself  in  the  eyes. 

This  is  a  very  common  and  very  misleading  fact. 
The  patient  finds  it  hard  to  believe  that  medicine 
ought  seldom  to  be  put  on  the  spot  where  he  feels 
his  pain.  If  the  pain  is  in  his  stomach  he  wants  some 
medicine  to  put  in  his  stomach  and  not  a  harangue 
on  his  habits,  which  is  usually  the  only  thing  we  can 
really  do  to  help  him.  If  he  has  a  pain  in  his  back  he 
wants  a  plaster  or  a  Uniment  for  his  back.  It  is  very 
hard  to  get  people  out  of  that  habit  of  mind,  and 


114  SOCIAL  WORK 

we  shall  surely  fail  unless  we  are  clear  about  it  our- 
selves. It  must  be  perfectly  clear  in  our  minds,  or 
better,  in  our  own  experience,  that  fatigue  may  be 
referred  to  one  spot  or  to  another,  in  such  a  way  as 
seriously  to  mislead  us.  I  suppose  that  half  of  all  the 
pains  that  we  try  to  deal  with  in  a  dispensary  —  and 
pain,  of  course,  is  the  commonest  of  complaints  — 
are  not  due  to  any  local  or  organic  disease  in  the 
part.  Doubtless  there  are  some  wholly  unexplored 
diseases  or  disturbances  of  nutrition  in  that  part,  as 
there  may  be  in  the  eyes  when  they  ache  because 
you  have  been  walking  up  a  mountain.  But  medical 
science  knows  nothing  about  that.  What  we  do 
know  is  that  the  pain,  if  it  is  to  be  helped,  will  be 
helped  not  by  thinking  about  that  spot  or  doctoring 
it,  but  by  trying  to  get  that  person  rested. 

Fatigue,  then,  ought  to  be  one  of  our  comjnonest 
medical-social  diagnoses,  and  to  help  people  out  of  it, 
one  of  the  attempts  that  we  most  often  make.  In 
Dec,  1917,  a  dozen  or  more  Y.M.C.A.  boys  con- 
sulted me  in  France,  all  with  coughs,  all  wanting 
medicine  to  stop  the  cough,  and  most  of  them  a  good 
deal  disappointed  because  they  were  told  to  go  home 
and  go  to  bed,  told  that  they  were  tired,  and  that 
this  fact  depressed  their  resistance  against  bacteria, 
so  that  bronchitis  or  broncho-pneumonia  resulted. 

The  second  point,  then,  that  one  wants  to  make 
about  fatigue  is,  that  it  is  the  commonest  cause  of 
infectious  disease.  Pasteur's  great  discovery,  which 
set  modern  medicine  upon  the  right  bases,  some- 


FATIGUE  AND  REST  115 

times  gets  twisted  out  of  perspective.  Sometimes  we 
fail  to  realize  that  the  seed  may  fall  upon  stony 
ground.  The  seed,  of  course,  is  bacteria,  and  its  dis- 
covery was  Pasteur's  immense  service  to  humanity. 
But  Pasteur  was  so  busy  that  he  did  not  emphasize 
the  truth  that  a  seed  can  fall  upon  good  ground  or 
upon  bad  ground.  When  bacteria  fall  upon  bad 
ground,  that  is,  upon  healthy  tissue,  they  do  not 
grow,  they  do  not  spring  up  and  multiply.  Tired  tis- 
sues, as  has  been  abundantly  proved  by  animal  ex- 
perimentation, are  prone  to  infection.  They  are  good 
soil  for  the  growth  of  bacteria.  It  is  true  generally;  it 
is  true  locally.  A  part  that  has  been  injured,  for  in- 
stance, a  part  that  has  been  bruised  without  any 
break  in  the  skin,  without  the  entrance  of  any  infec- 
tion from  the  outside,  is  damaged  by  something  that 
hurts  its  resisting  power  as  fatigue  does.  Such  a  part 
will  often  become  inflamed,  will  often  become  sub- 
ject to  the  action  of  bacteria  which  must  have  been 
in  the  body  already,  but  which  had  been  kept  on 
the  frontier  by  our  powers  of  resistance. 

Our  "powers  of  resistance,"  then,  which  we  cannot 
more  definitely  name,  which  we  do  not  as  yet  know 
to  be  identified  with  leucocytes  or  with  anything 
else,  can  get  tired.  When  they  get  tired  we  "catch" 
a  cold  or  a  diarrhea,  or  a  hundred  things  which 
seem  to  have  nothing  to  do  with  fatigue,  but  have 
nevertheless. 

Accumulated  fatigue  or  physical  debt.  If  you  go  up 
a  long  flight  of  steps  at  a  moderate  rate,  you  can  get 


116  SOCIAL  WORK 

to  the  top  without  being  tired ;  if  you  go  up  at  a  rapid 
rate,  as  most  of  us  do,  you  are  tired  at  the  top. 
Physically  you  put  out  the  same  amount  of  energy, 
I  suppose.  I  do  not  see  that  there  can  be  any  con- 
siderable difference  in  the  energy  consumed  by  the 
performance  of  that  act  whether  we  do  it  slowly  or 
quickly.  The  difference  is  that  in  the  first  case  we 
rest  between  each  two  steps  as  we  rest  between  each 
two  days  at  night.  When  our  activities  are  so  bal- 
anced as  not  to  run  in  debt,  we  rest  between  each 
two  steps.  You  and  I  can  walk  at  our  individual 
peculiar  gait  on  the  level  for  a  long  time  without 
any  accumulation  of  fatigue,  often  with  refreshment. 
But  push  us  and  we  are  soon  exhausted.  Suppose 
that  our  normal  walking  rate  is  three  and  a  half 
miles  an  hour;  push  us  to  four,  and  it  may  not  be  a 
quarter  of  a  mile  before  we  are  done  up,  because  we 
have  not  been  able  to  avoid  accumulated  fatigue  by 
resting  between  each  two  steps.  It  has  been  said  that 
in  rowing  the  crew  that  wins  is  the  crew  that  rests 
between  each  two  strokes.  The  person  who  does  not 
get  tired  is  the  person  who  rests  between  each  two 
days.  He  does  not  accumulate  fatigue.  It  is  the  ac- 
cumulation that  finally  breaks  you,  makes  you  bank- 
rupt. It  is  the  little  unnoticed  bit  added  day  by  day, 
week  by  week,  month  by  month,  that  makes  the 
break. 

Fatigue  we  should  think  of  as  running  in  debt. 
One  of  the  figures  of  speech  that  has  served  me  best 
in  teaching  patients  how  to  live  is  that  figure  of  in- 


FATIGUE  AND  REST  117 

come  and  outgo.  I  have  often  said  to  people,  "Phy- 
sically you  are  spending  more  than  you  earn,  not  to- 
day merely,  but  right  along.  You  must  earn  more 
than  you  spend.  You  must  get  a  plus  balance  in  the 
bank.  Then  you  can  run  along  with  fatigue  or  ill- 
ness." 

That  figure  of  speech  helps  us  also  to  express  an- 
other fact  about  fatigue,  which  is  important  to  rec- 
ognize in  ourselves  and  in  our  patients,  because 
otherwise  we  get  thrown  off  the  track:  delayed  fa- 
tigue. The  first  day  that  your  income  begins  to 
be  less  than  your  expenditures,  nothing  necessarily 
happens.  The  bank  does  not  proclaim  that  there  is 
no  deposit  there.  It  is  some  days  later,  usually,  that 
you  begin  to  reap  your  troubles.  It  is  the  same  in 
physical  fatigue.  Patients  say  to  us,  "I  slept  ten 
hours  last  night.  I  spent  a  virtuous  Sunday.  Why 
should  I  be  tired  to-day?"  We  should  answer,  "Be- 
cause of  something  you  did  last  Tuesday  or  there- 
abouts." We  all  are  familiar  with  this  in  relation  to 
sleep.  It  is  not  the  day  after  a  bad  night,  but  several 
days  later  that  its  effects  depress  us. 

Delayed  fatigue,  then,  is  an  important  thing  to 
notice  in  ourselves  and  to  bring  home  to  the  people 
that  we  are  trying  to  help.  I  suppose  one  could  say 
that  a  great  part  of  our  business  in  social  work  is  to 
call  people's  attention  to  things;  if  they  have  recog- 
nized them  before,  they  will  perhaps  get  a  lesson  out 
of  what  we  say.  Such  matters  are  referred  fatigue,  de- 
layed fatigue,  accumulated  fatigue, — familiar  enough. 


118  SOCIAL  WORK 

only  the  person  does  not  act  on  them  because  he 
does  not  notice  them. 

The  fatigue-rest  rhythm,  the  alternation  of  fa- 
tigue and  rest,  I  have  already  phrased  by  the  meta- 
phor of  earning  and  spending.  You  can  phrase  it  also 
by  a  metaphor  very  close  to  the  physical  facts  as  we 
know  them,  the  metaphor  of  building  up  and  tearing 
down.  During  the  daytime,  from  the  point  of  view  of 
physiology  and  the  workings  of  the  body,  we  burn 
up  tissue.  In  us  oxidation  processes  are  going  on 
which  are  really  burning,  as  really  as  if  we  saw  the 
flame.  Tissue  is  being  destroyed,  broken  down,  going 
off  in  the  form  of  heat,  energy,  and  life.  That  is  good 
in  case  it  is  followed,  as  it  should  be,  by  a  period  of 
rest  in  which  we  build  up.  Presumably,  if  we  could 
see  with  adequate  powers  of  the  microscope  or  pow- 
ers of  observation  of  some  sort,  what  goes  on  during 
rest,  we  should  see  a  perfect  fever  of  rebuilding  all 
that  we  have  torn  down  during  the  day.  People  often 
say,  "Shall  I  take  exercise?"  Yes,  but  remember 
that  half  of  the  process  of  taking  exercise  is  get- 
ting rested  afterwards.  It  will  do  you  good  provided 
you  rest  after  it,  provided  what  has  been  torn  down 
in  exercise  is  replaced  by  sufTicient  tissue  or  fresh 
power  in  rest. 

The  English  studies  of  fatigue  to  which  I  have  re- 
ferred have  been  of  great  importance  because,  so  far 
as  I  know,  they  are  the  first  attempt  we  have  had  in 
the  way  of  testing  when  men  or  women  in  industry 
are  too  tired  and  how  much  too  tired  they  are.  I  do 


FATIGUE  AND  REST  119 

not  suppose  that  any  employer  of  labor  would  want 
for  his  own  profit  or  for  more  than  a  short  time  to 
overwork  people  in  this  sense,  if  he  had  the  facts 
called  to  his  attention.  If  he  realized  what  he  was  do- 
ing, he  would  not  want  to  break  down  his  working 
force  any  more  than  he  would  to  spoil  his  machin- 
ery. But  some  employers  are  careful  of  their  steel 
machinery  and  careless  of  their  human  machinery. 
They  will  continue  to  be  so,  I  fear,  until  we  know 
more  about  fatigue. 

It  is  one  of  the  most  difficult  things  to  measure 
that  I  know.  Take  it  in  your  own  case:  what  tires 
you  one  day  does  not  tire  you  another  day.  The 
individuality  of  it,  the  disturbing  factors  when 
we  try  to  measure  it,  are  perfectly  extraordinary. 
Such  a  disturbing  factor  in  our  calculations  is  "sec- 
ond wind"  —  mental  or  physical.  A  number  of  men 
marching  along  will  grow  less  tired  as  time  goes  on 
by  the  acquisition  of  what  we  call  "second  wind." 
We  do  not  know  what  it  is.  We  have  tried  to  connect 
it  with  the  condition  of  the  heart,  to  say  that  the 
heart  finally  gets  to  deal  with  the  volume  of  blood 
that  is  running  through  it  so  that  there  is  no  over- 
plus of  blood  stored  in  any  one  chamber  at  any 
moment.  But  we  do  not  really  know  anything  about 
that.  We  do  not  know  what  second  wind  is;  but  it  is 
important  to  know  that  it  exists. 

Moreover,  as  Professor  William  James  pointed 
out  in  that  essay  called  "The  Energies  of  Men," 
there  are  "mental  second  winds."  Just  when  a  man 


120  SOCIAL  WORK 

is  worn  out  he  often  finds  new  strength.  He  often 
cannot  get  his  best  strength  until  he  pushes  himself 
even  to  despair.  In  the  spiritual  experiences  of  the 
world's  saints  and  heroes  we  find  that  it  was  just 
when  it  seemed  as  if  they  were  about  to  go  under 
that  this  second  wind,  or  third  wind,  for  it  sometimes 
comes  again  and  again,  this  mitigation  of  fatigue 
without  rest,  comes  to  them.  This  is  a  most  disturb- 
ing fact.  If  we  were  hke  a  pitcher  which  is  emptied 
out  and  filled  up,  we  should  know  all  about  fatigue 
very  soon.  We  are  like  a  pitcher  to  a  certain  extent, 
but  the  similarity  is  disturbed  by  such  factors  as 
second  wind,  and  disturbed,  moreover,  by  mental 
and  emotional  intruders  like  music.  A  military  band 
coming  upon  a  body  of  marching  men  will  give  them 
strength  when  they  had  no  strength.  That  is  not  a 
sentimental  but  a  practical  fact  which  army  men 
have  to  take  advantage  of.  Then  the  fact  that  many 
people  can  rest  by  change  of  work  without  stopping, 
is  also  disconcerting.  We  say  to  a  person,  "You  have 
been  working  hard  all  day;  you  must  stop,  he  down, 
go  to  bed."  That  person  disobeys,  keeps  going  on 
something  different,  is  altogether  fresh  next  morn- 
ing, and  we  have  to  confess  that  we  were  wrong. 

It  is  a  very  familiar  experience  that  one  may  be 
almost  dead  from  one  point  of  view,  but  quite  fresh 
from  another,  as  one  wants  no  more  meat,  but  has 
plenty  of  room  for  dessert.  Some  people  can  rest  by 
change  of  work  and  some  cannot.  It  is  very  impor- 
tant for  us  to  keep  finding  out  in  a  great  number  of 


FATIGUE  AND  REST  121 

ways  which  of  the  classes  into  which  people's  bodies 
are  divided  we  each  belong  to.  Do  we  belong  in  the 
class  of  the  people  who  must  get  their  rest  by  giving 
up,  by  the  abolition  of  all  function,  or  in  the  class 
who  rest  by  the  change  of  function,  by  doing  some- 
thing different  from  the  day's  work?  It  is  a  question 
of  fact  and  must  be  found  out  by  each  individual  for 
himself. 

Just  here  the  individuality  of  fatigue,  which  I  have 
been  trying  to  make  clear  all  along,  becomes  obvious. 
We  are  rested  by  making  a  success  of  something.  If 
we  have  been  making  what  seems  to  us  a  failure  of 
something,  it  is  amazing  how  it  rests  us  to  make  a 
success  of  something.  The  boat  crew  that  wins  is  al- 
most never  tired  at  the  finish;  the  crew  that  loses  is 
almost  always  dead  tired.  That  is  why  it  is  so  re- 
freshing to  go  home,  to  have  a  home  to  go  to,  and 
somebody  to  go  to  in  that  home,  because  there  you 
have  a  tiny  success.  You  have  built  up  that  home;  it 
represents  your  savings,  perhaps,  if  you  are  a  work- 
ing-man, or  your  success  in  winning  somebody's  af- 
fections. That  success  is  hnked  up  with  joy.  Recrea- 
tion re-creates  us  because  it  enables  us  to  succeed 
when  we  have  felt  ourselves  failures,  or  at  any  rate 
postponers.  We  are  working  for  some  "far-off  divine 
event  to  which"  (we  hope)  "creation  moves,"  but 
moves  very  slowly.  In  recreation,  in  art,  in  beauty, 
in  going  to  the  theatre,  dancing,  music,  we  get  at 
something  where  we  can  succeed,  success  by  per- 
formance or  by  enjoyment  and  so  be  refreshed. 


122  SOCIAL  WORK 

One  of  the  things  that  is  always  exasperating  to  stu- 
dents of  industrial  fatigue  is  that  a  girl  who  is  nearly 
dead  from  working  in  a  factory  is  sometimes  made 
totally  fresh  by  dancing.  After  being  tired  out  by 
standing,  she  gets  rested  by  dancing.  It  is  certainly 
puzzling  but  not  inconceivable  if  we  take  into  ac- 
count the  psychical  factors,  which  we  are  so  apt  to 
ignore  because  they  are  invisible. 

One  of  the  things  we  want  in  rest  is  success  where 
we  have  felt  ourselves  failures,  achievement  where 
we  have  felt  we  were  postponing,  trying  to  make 
goods  which  we  never  see  finished,  of  which  we  do 
only  a  little  piece.  To  balance  all  that,  we  want 
achievement,  success,  finish,  the  present  delivery  of 
something  that  is  enjoyed  now,  of  home,  affection,  or 
beauty. 

From  another  point  of  view,  a  test  of  rest  is  for- 
geifulness.  Forgetfulness  ought  to  be  achieved  in 
our  recreation  and  our  time  oiT.  When  people  ask, 
"What  form  of  exercise  shall  I  take?"  we  have  to 
bear  in  mind  that  the  form  of  exercise  which  is  most 
valuable  is  that  which  makes  us  forget.  The  easiest 
form  of  exercise,  and  the  least  valuable,  usually,  is 
walking.  Many  people  carry  on  while  walking  just 
the  same  train  of  thought  that  has  tired  them.  If  so 
the  walk  is  nearly  useless.  For  other  people  the  act 
of  walking  is  different  enough  from  what  they  do,  so 
that  it  will  break  the  continuity  of  thought  and 
achieve  forgetfulness  and  rest.  Well-to-do  people 
who  can  run  an  automobile  usually  can  forget.  That 


FATIGUE  AND  REST  123 

has  been  a  little  good  that  has  come  out  of  the  many 
evils  of  the  automobile. 

One  of  the  good  signs  in  modern  education  is  that 
our  old-fashioned  gymnasiums  are  being  stripped 
bare,  the  apparatus  "scrapped,"  in  order  to  give 
place  to  play  a  game.  Playing  a  game  gives  us  pres- 
ent joy,  the  first  thing  we  want  in  recreation;  and 
in  the  second  place,  it  makes  us  forget. 

I  have  spoken  of  rest  through  change  of  work. 
But  the  change  ought  to  be  such  as  sets  free  impris- 
oned, unused  faculties  that  find  no  outlet  in  our 
daily  work.  It  may  be  that  marriages  are  made  in 
heaven,  but  the  marriage  of  a  man  to  his  job  is  very 
seldom  made  in  heaven,  and  so  mismating  is  com- 
mon. The  whole  human  race  is  too  big  for  its  jobs. 
The  industrial  system  is  altogether  too  small  to  fit 
us;  —  a  large  part  of  our  powers  remain  unused. 
Therefore,  the  purpose  of  our  time  for  rest  and  recre- 
ation, our  evenings  and  our  Sundays,  should  be  to 
even  up  that  balance,  to  use  the  part  of  us  that  is 
not  used  at  other  times.  Sunday  ought  to  be  a  fam- 
ily day,  just  because  in  the  working  world  people  do 
not  see  much  of  their  families  during  the  week;  it 
ought  to  be  a  day  in  the  country  because  we  have 
organized  these  things  called  cities  and  live  in  them 
during  the  week.  It  ought  to  be  a  day  of  worship  be- 
cause we  forget  our  religion  so  much  in  the  week's 
work.  Everything  that  we  do  on  Sundays  ought  to 
be  an  evening-up  of  what  gets  crowded  out  of  our 
V  eek-day  lives. 


124  SOCIAL  WORK 

Tests  of  fatigue 

The  English  tests  of  fatigue  are  nowhere  near  be- 
ing apphed  yet  in  America  or  anywhere  else  as  we 
hope  some  day  they  will  be,  to  solve  this  tremendous 
problem  of  industrial  fatigue  and  industrial  disease. 
In  some  of  the  ammunition  works  in  England  ^  they 
took  a  body  of  people  of  approximately  the  same  age 
and  sex,  living  under  the  same  conditions  approxi- 
mately, doing  the  same  work.  They  changed  the 
working  hours  of  one  set  and  left  the  other  set 
unchanged  as  a  "control."  In  any  scientific  test 
we  have  to  have  what  we  call  a  "control,"  some- 
thing that  enables  us  to  compare  the  changes  that 
we  bring  about  experimentally  with  the  unchanged 
state  of  things. 

(a)  In  one  room  the  hours  of  labor  were  left  un- 
modified, in  the  other  modified,  first  increased,  then 
decreased.  They  made  interesting  experiments  to  see 
whether  a  man  produced  as  much  output,  in  eight 
hours  as  he  could  in  ten;  they  showed  that  he  could 
produce  as  much  in  the  shorter  time  as  he  could  in 
the  longer  time,  presumably  because  he  was  less 
tired,  less  bored,  less  strained.  They  made  a  further 
cut  and  found  that  then  he  did  not  produce  as  much. 
There  is  a  limit,  therefore.  He  could  not  probably 
produce  as  much  in  four  as  in  eight  hours. 

Then  they  experimented  on  continuity  and  dis- 

^  See  Health  of  Munition  Workers  Committee.  Final  Report,  In- 
dustrial Health  and  Efficiency.  (London,  19 18.) 


TESTS  OF  FATIGUE  125 

continuity  of  work  —  whether  a  person  could  pro- 
duce as  much  or  more  in  five  continuous  hours  as  in 
two  batches  of  two  and  a  half  hours  with  rest  in  be- 
tween. They  found  that  the  shorter  periods  did  dis- 
tinctly better. 

Output,  then,  was  the  first  rough,  but  still  service- 
able, test  that  they  used  in  relation  to  fatigue. 

(b)  Next  they  recorded  the  general  look  and  feel- 
ing of  the  men  as  the  foreman  and  other  interested 
people  could  size  it  up  —  the  look  of  listlessness,  of 
boredness,  of  fatigue  in  the  working-man  when  they 
varied  the  hours  and  continuity  of  work  in  the  ways 
that  I  have  spoken  of. 

(c)  Next  they  took  the  amount  of  illness,  of  time 
off,  away  from  work,  as  a  measure  of  fatigue,  and  it 
was  very  definitely  shown  that  with  a  diminished 
number  of  hours  the  number  of  sicknesses  of  all 
kinds,  such  as  colds,  were  diminished,  illustrating  the 
point  that  I  made  a  moment  ago,  —  that  accumu- 
lated fatigue  diminishes  our  resistance  to  infection. 

(d)  Finally,  they  made  some  physiological  tests 
of  powers  of  sight,  quickness  of  answer,  etc.,  after 
fatigue,  and  showed  that  a  man  was  less  keen  in  his 
senses,  less  capable  of  accurate  response,  after  a  cer- 
tain number  of  hours'  work  than  before,  and  that 
fatigue  could  to  a  certain  extent  be  measured  in 
that  way. 

All  these  tests  of  fatigue  can  be  applied  in  our  lives 
and  in  the  lives  of  people  we  are  trying  to  help  in 


126  SOCIAL  WORK 

social  work.  We  have  to  take  account  of  the  num- 
ber of  hours,  the  possible  breaks,  intervals,  that  can 
be  made  in  otherwise  continuous  labor.  Many  peo- 
ple can  get  on  very  well  if  they  break  the  day  into 
manageable  fragments.  We  must  also  take  account 
of  the  effect  of  fatigue  in  producing  infectious  dis- 
ease, of  the  general  look  of  the  person,  and  of  such 
little  physiological  lapses  as  I  have  spoken  of,  weak- 
ened attention,  the  capacity  for  forgetting  names, 
and  mental  numbness  or  the  sense  that  things  are 
unreal. 

In  dispensary  work,  when  we  try  to  give  up  the 
use  of  particular  medicines  which  are  useless  (as 
contrasted  with  the  medicines  that  are  useful),  one 
of  the  chief  things  to  put  in  their  place  is  the  study 
of  fatigue  and  of  the  methods  for  resting  our  pa- 
tients. We  cannot  make  the  social  work  of  a  medi- 
cal-social clinic  successful  unless,  whenever  we  take 
away  something  which  we  know  to  be  a  fraud  and 
an  untruth,  w^e  put  something  else  in  its  place.  It  is 
for  that  reason  that  I  have  devoted  so  much  space 
to  the  subject  of  fatigue  and  rest. 


CHAPTER  VII 

THE  SOCIAL  worker's  BEST  ALLY  —  NATURE'S  CURE 
OF  DISEASE 

Fatigue  is  a  matter  that  seems  to  me  of  particular 
importance  in  social  work  for  two  reasons:  first,  be- 
cause it  concerns  the  visitor's  own  work  and  the  way 
she  does  it;  and  second,  because  it  concerns  the  trou- 
bles of  a  large  proportion  of  all  patients.  The  ulti- 
mate diagnosis,  if  we  could  make  it,  in  probably- 
half  of  all  the  people  who  come  to  a  general  chnic,  is 
fatigue  of  some  form,  f alhng  upon  the  weakest  organ 
or  function. 

I  want  to  connect  this  subject  of  fatigue  with  one 
of  the  policies  which  should  govern  medical-social 
work,  namely,  that  we  should  be  honest  both  in 
diagnosis  and  in  treatment.  That  is  a  policy  for 
which  I  have  struggled  and  fought  for  a  long  time, 
but  which  we  are  still  far  from  attaining.  We  have 
not  yet  an  honest  practice  of  medicine  on  any  large 
scale,  a  frank  declaration  to  patients  of  what  ails 
them,  how  they  may  avoid  its  recurrence  and  so 
avoid  coming  to  the  doctor  again.  In  the  American 
Red  Gross  Dispensaries  in  France  we  tried  to  pur- 
sue the  policy  of  honesty  in  diagnosis  and  treatment. 
We  were  told  by  wise  people  at  the  beginning  that 
it  would  not  work  there,  that  with  French  patients 
it  would  not  do  to  explain  carefully  and  honestly 


128  SOCIAL  WORK 

what  was  the  matter  or  to  refuse  to  give  them  drugs 
when  we  knew  that  drugs  were  no  use.  But  one  of 
the  pleasantest  experiences  of  our  war  work  was 
to  find  that  this  warning  was  not  true.  We  used 
the  truth  exclusively  and  successfully.  Our  success 
seemed  to  me  natural  because  on  the  whole  the 
French  are  the  most  intelligent  race  that  I  have  ever 
come  in  contact  with.  Hence  they  took  to  this  par- 
ticular part  of  our  pohcy  even  better  than  people 
take  to  it  in  America. 

That  policy  links  itself  up  with  the  management 
of  diseased  states  due  to  fatigue  and  with  the  ex- 
planation of  how  to  prevent  getting  into  poor  condi- 
tion again.  In  newspaper  advertisements  and  adver- 
tisements in  the  street-cars,  it  is  the  fashion  to  state 
that  a  given  remedy,  a  given  panacea,  ''will  cure 
you  in  spite  of  yourself.'*  That  is  exactly  what  the 
patient  wants.  He  wants  to  be  put  in  perfect  condi- 
tion by  the  first  of  March,  we  will  say.  Inquiring  into 
his  present  distress  we  almost  always  find  that  he 
has  been  violating  in  some  obvious  way  some  hy- 
gienic law.  But  he  wants  to  be  cured  without  reform, 
in  spite  of  persisting  in  his  bad  habits  of  eating,  drink- 
ing, sleeping,  working,  worrying  —  to  be  cured  by 
means  of  miraculous  interference  which  he  thinks  a 
drug  will  produce.  He  wants  a  tonic,  and  he  often 
does  not  take  it  well  when  you  tell  him  that  there  is 
no  such  thing  as  a  tonic.  There  never  was  and  pre- 
sumably there  never  will  be  such  a  thing.  A  tonic  is  a 
thing  which  does  nature's  work,  which  gives  us  in  a 


NATURE'S  CURE  OF  DISEASE      129 

moment  artificially  what  food  and  sleep  and  air  and 
rest  and  recreation  slowly  and  naturally  give  us. 
There  is  no  such  thing.  The  nearest  thing  we  have  to 
a  tonic  —  a  thing  which  we  sometimes  give  when 
people  ask  for  a  tonic  —  is  an  appetizer.  There  are 
drugs  which  will  help  a  little  in  giving  an  appetite. 
But  only  to  that  extent  can  we  give  a  tonic.  But  this 
is  not  what  people  want  to  be  told.  They  want  some- 
thing to  take  away  "that  tired  feeling."  There  is  one 
thing  (as  unfortunately  people  discover  only  too 
soon)  which  will  take  away  the  feeling  of  fatigue 
—  alcohol.  That  is  why  people  take  it,  because  alco- 
hol, a  narcotic  as  it  always  is,  dulls  the  sense  of  fa- 
tigue, and  allows  people  to  go  ahead  straining  them- 
selves, when  they  ought  to  have  been  compelled  by 
nature's  warnings  to  stop.  Perhaps  it  is  because 
so  many  "tonics"  contain  alcohol  that  people  have 
not  got  over  the  idea  that  there  is  any  such  thing  as 
a  real  tonic,  which  abohshes,  not  the  awareness  of 
fatigue,  but  the  fatigue  itself. 

The  promise  to  "cure  you  in  spite  of  yourself," 
then,  is  the  bait  by  which  the  quack  attempts  to 
tempt  us,  and  his  lie  shows  exactly  the  line  in  which 
we,  as  social  workers  or  as  physicians  in  a  dispen- 
sary, ought  to  labor.  We  must  try  to  show  people 
that  fatigue,  strain,  worry,  and  other  natural  causes 
have  brought  them  where  they  are,  and  that  there  is 
no  possible  getting  out  of  their  troubles  without  fol- 
lowing the  line  of  common  sense.  No  drug,  no  tonic, 
can  take  the  place  of  obedience  to  conmion  sense. 


130  SOCIAL  WORK 

We  see  people  who  have  varicose  veins,  for  in- 
stance, and  whose  work  forces  them  to  stand  a  great 
deal  on  their  feet.  They  often  come  to  us  hoping  to 
get  cured  in  spite  of  the  fact  that  they  are  standing  all 
the  time,  and  inviting  the  force  of  gravity  to  produce 
stagnation  of  blood  in  their  legs.  In  advising  such 
people  we  have  two  courses  open  to  us,  quite  charac- 
teristic of  the  courses  which  may  be  followed  in  all 
such  matters: 

1.  We  can  say,  "Well,  I  understand  that  you 
really  cannot  arrange  to  get  off  your  feet.  All  right. 
The  varicose  veins  will  not  get  cured.  But,  on  the 
other  hand,  they  are  not  very  dangerous;  the  conse- 
quences of  neglecting  them  are  not  very  serious. 
The  number  of  cases  when  an  over-distended  vein 
breaks  and  causes  a  serious  hemorrhage  is  not  great. 
The  chances  of  ulcer  are  not  very  great."  Force  the 
patient  to  face  the  danger  and  realize  what  will  hap- 
pen, in  case  he  does  not  make  any  change  in  his  hab- 
its; it  is  then  perfectly  proper  in  certain  cases  for  a 
person  to  go  on  violating  hygienic  common  sense 
provided  he  has  counted  the  cost  and  faced  it. 

Each  of  us  comes  to  some  point  in  his  life  when  he 
makes  up  his  mind  that  for  a  good  cause  he  will 
smash  his  health.  I  do  not  believe  in  the  worship  of 
health.  There  are  many  better  things  in  the  world 
than  health.  Many  a  man  makes  up  his  mind  to  do 
what  he  knows  will  probably  cost  him  a  number  of 
weeks  or  a  year  of  his  life.  That  is  all  right;  only  we 
must  face  it,  in  peace  as  well  as  in  war. 


NATURE'S  CURE  OF  DISEASE      131 

Or  (2),  when  people  come  to  us  for  the  rehef  of 
skin  abscesses,  boils,  and  demand  some  drug  which 
will  cure  these  abscesses,  we  must  ask  the  impor- 
tant questions.  Whence  did  you  get  them?  Why  did 
they  come?  Presumably  not  because  the  patient  has 
failed  to  take  a  drug.  We  must  find  the  fault  in  hy- 
giene, generally  constipation  or  overwork,  or  lack  of 
sleep,  causing  a  lowering  of  the  body's  vital  resist- 
ance, whereby  the  germs,  the  staphylococci,  which 
are  deep  in  our  skin  and  never  to  be  rubbed  off  by 
any  washing  or  sterilization,  begin  to  multiply.  The 
soil  has  become  such  that  they  can  multiply. 

I  have  tried  to  suggest  the  importance  that  we 
ought  to  attribute  to  soil  as  well  as  to  seed.  Modern 
doctrine  about  the  cause  of  disease  has  called  our  at- 
tention to  the  tremendous  importance  of  seed,  that 
is,  germs,  bacteria.  But  on  the  whole,  if  one  had  to 
say  which  is  the  most  important  single  factor  in  dis- 
ease, he  would  have  to  say,  not  the  seed,  but  the  soil. 
Take  the  tuberculosis  bacillus,  for  instance.  I  do  not 
think  it  is  an  exaggeration  to  say  that  nine  tenths  of 
all  persons  have  had  tuberculosis,  usually  in  a  harm- 
less form,  because  the  soil  has  been  stony  and  so  has 
killed  off  the  bacteria.  You  know  that  the  figures  ob- 
tained by  means  of  tests  with  the  Von  Pirquet  reac- 
tion in  almost  any  city  or  town,  show  that  ninety 
per  cent  of  the  children  of  twelve  years  of  age  and 
on,  have  a  positive  reaction  to  this  test  for  infection 
by  tuberculosis.  They  have  the  tuberculosis  bacillus 
somewhere  in  their  bodies.  That  does  not  mean  that 


132  SOCIAL  WORK 

they  have  the  disease,  but  they  have  the  bacteria  in 
their  bodies,  and  mostly  in  the  process  of  being  killed 
of!  by  the  tissues  of  the  body  which  resist  this  infec- 
tion. 

One  of  the  reasons  why  I  go  into  detail  here  about 
the  changes  that  take  place  in  the  body  through 
disease,  is  to  mal^e  social  workers  feel  as  strongly  as 
I  feel,  and  convey  to  patients  as  strongly  as  I  tr>'  to 
convey  it,  what  nature  does  in  curing  disease.  We  have 
read  of  people  who  were  walled  up  in  masonry  by 
way  of  vengeance,  and  left  to  die  in  a  casket  of  stone. 
That  is  what  nature  does  to  a  bacillus,  hterally  walls 
it  off  in  stone.  After  death  when  the  pathologist's 
knife  cuts  down  into  a  lung,  the  knife  is  sometimes 
broken  by  coming  upon  what  feels  like  a  stone.  A 
stone  it  really  is,  a  deposit  of  lime  salts  in  the  tissue, 
around  a  nest  of  tubercle  baciUi.  If  one  cuts  such  a 
stone  in  two,  one  fmds  in  the  centre  baciUi  often 
still  alive  and  perfectly  capable  of  increase,  but 
harmless  to  the  body  because  nature  has  built  this 
wall  around  them.  I  do  not  think  one  can  get  the 
full  force  of  this  fact  until  one  has  seen  it.  That  is 
one  of  the  long  hst  of  things  that  the  body  is  con- 
stantty  doing  in  this  process  of  resisting  disease,  and 
doing  more  intelligently  than  we  can. 

Since,  then,  it  is  chiefly  the  soil,  the  vital  condition 
of  our  tissues,  which  resists  disease,  we  must  do  our 
part  in  maldng  that  soil  good  or  bad  for  disease. 
That  is  why  our  hygiene,  our  obedience  to  the  indi- 
vidual lav%-s  of  our  ov;n  experience,  VN'hich  show  us 


NATURE'S  CURE  OF  DISEASE      133 

how  we  can  keep  well  and  how  we  get  sick,  must  be 
learned  and  taught  by  every  one  of  us  so  far  as  we 
can  m  such  a  place  as  a  dispensary  or  a  patient's 
home. 

For  example:  disease  is  often  produced  by  lack  of 
sleep ;  hence  it  is  of  central  importance  to  teach  peo- 
ple how  to  sleep.  Excluding  organic  disease  in  the 
causation  of  most  cases  of  sleeplessness  —  for  most 
people  suffering  from  insomnia  do  not  have  organic 
disease  —  one  can  say  this:  Insomnia  usually  de- 
pends on  something  wrong  in  the  patient's  day.  The 
state  of  the  night  depends  on  the  state  of  the  day. 
If  the  day  has  been  free  not  merely  from  gross  sin, 
but  free  from  hygienic  blunder,  then  the  night  will 
go  somewhere  nearly  right.  If  the  day  has  been  filled 
with  concentrated  work  in  which  the  mind  has  been 
wholly  upon  the  thing  it  has  in  hand,  if  there  have 
been  no  elements  of  strain  through  distraction  or 
worry,  causing  double  currents  in  the  mind,  then 
when  night  comes  one  can  turn  the  mind  off  and  go 
to  sleep.  On  the  other  hand,  the  mind  which  has 
been  intent  half  on  its  own  job  and  half  on  its  own 
worries,  never  wholly  "turned  on"  during  the  day, 
cannot  be  "turned  off"  at  night.  Any  physician  or 
any  patient  succeeds  in  curing  insomnia  who  suc- 
ceeds in  finding  out  what  is  wrong  in  the  way  the 
sleepless  person  lives,  and  how  it  can  be  corrected. 

But  most  people  want  to  go  on  Uving  in  just  the 
same  stupid  way  and  yet  to  get  rid  of  the  sleepless- 
ness "in  spite  of  themselves."  The  obvious  way  is  to 


134  SOCIAL  WORK 

take  a  drug  that  for  a  while  will  stop  insomnia  even 
when  life  goes  on  as  before.  There  are  many  drugs 
that  will  give  sleep,  but  there  are  no  harmless  drugs 
that  give  sleep  —  none.  Physicians  receive  about 
once  a  year  advertisements  of  a  drug  for  sleep  which 
is  "wholly  without  ill  effects,"  but  I  do  not  think  it 
shows  undue  skepticism  or  dogmatism  to  say  that 
those  drugs  never  do  what  they  say,  and  never  will. 
Sleep  being  a  natural  process,  anything  that  forces 
it  upon  us  hardly  can  be  free  from  ill  effects.  Hence 
the  first  thing  in  attacking  a  case  of  insomnia  is  to 
say,  "Never  take  a  drug  again."  Natural  processes 
whereby  fatigue  accumulates  and  puts  us  to  sleep  do 
not  go  on  rightly  if  we  are  being  artificially  driven 
into  sleep  by  a  drug. 

One  gives  drugs  for  sleeplessness  rightly  when 
there  is  some  rare  and  special  reason  for  being 
awake,  some  catastrophic  reason  which  will  never 
occur  again.  This  exemplifies  the  principle  which  I 
have  tried  to  emphasize  throughout  this  book.  We 
may  give  money  for  some  catastrophic  cause  which 
puts  the  person  down  and  out,  and  will  not  occur 
again.  So  we  give  a  drug  for  sleeplessness  if  there  has 
been  some  special  thing  to  interfere  with  sleep  —  if, 
for  instance,  you  have  been  talking  very  hard  with  a 
friend  and  you  know  by  your  own  feelings  that  your 
mind  will  not  stop  that  night.  Then  you  may  per- 
fectly properly  take  a  drug  to  put  you  to  sleep, 
knowing  that  there  is  no  reason  to  suppose  that  such 
a  talk  will  occur  again  in  the  near  future.  Knowing 


NATURE'S  CURE  OF  DISEASE      135 

this,  you  do  not  need  to  waste  that  night.  You  take 
the  drug.  But  it  is  only  in  rare  catastrophic  mo- 
ments that  one  can  be  cured  in  spite  of  one's  self,  any 
more  than  one  can  give  or  take  money  safely. 

It  is  the  same  in  the  matter  of  constipation.  The 
first  thing  to  make  clear  to  a  patient  is  that  drugs 
must  be  abandoned  before  he  can  ever  teach  his 
bowels  to  behave  as  they  should.  But  it  is  a  great 
deal  of  trouble  to  do  that,  and  because  people  shirk 
that  trouble,  and  want  to  be  "cured  in  spite  of 
themselves,"  they  come  to  a  doctor  to  be  cured  by 
drugs.  Alas,  he  is  often  weak  enough  to  give  them 
what  they  seek! 

I  have  tried  to  make  this  drug-fearing  practice 
one  of  the  policies  that  honest  medicine  must  always 
stand  for,  because  it  seems  to  me  that  when  the  doc- 
tor allows  himself  to  be  tempted  into  behaving  as  a 
considerable  number  of  his  profession  do  —  that  is, 
into  giving  people  what  they  ask  for  —  he  very  soon 
loses  his  ideals,  gives  things  that  he  knows  more  and 
more  clearly  that  he  has  no  right  to  give,  and  goes 
downhill.  Social  assistants  must  help  the  doctor  to 
avoid  this  disaster.  They  can  do  so  by  helping  him 
to  teach  the  truth. 

I  want  to  deal  a  little  further  with  some  examples 
of  what  nature  does  in  the  way  of  warding  off  dis- 
ease. For  a  large  part  of  what  we  call  disease,  and 
what  we  feel  in  ourselves  as  disease,  is  not  the  attack 
of  the  enemy,  but  is  our  defence  agamst  the  enemy. 


136  SOCIAL  WORK 

Take,  for  instance,  inflammation.  When  germs 
are  beneath  the  skin,  one  finds  redness,  swelhng, 
heat,  pain,  as  the  symptoms  of  inflammation.  What 
does  that  mean?  It  is  aU  hke  the  defences  which 
were  set  up  round  Paris  when  the  Germans  were 
coming  there,  or  that  are  set  up  anywhere  when  one 
is  getting  ready  to  repel  attack.  The  inflamed  finger 
gets  red  because  a  great  deal  of  blood  is  going  there. 
The  blood  cells,  especially  the  white  ceHs  of  the 
blood,  are  coming  there  to  defend.  The  finger  gets 
red  for  the  same  reason  that  the  railroads  get  con- 
gested in  time  of  battle,  namely,  because  so  many 
soldiers  are  being  carried  there  for  defence.  The  fin- 
ger gets  swollen  because  so  many  cells  and  fluids  are 
coming  to  attack  the  enemy;  it  is  their  crowding 
outside  the  blood  vessels  that  makes  the  swelling. 
There  is  heat  in  the  finger  because  there  is  more 
blood  in  the  part  and  therefore  the  part  is  hotter. 
There  is  pain  because  with  the  extra  accumulation 
of  defenders  there  is  a  squeezing  of  the  little  nerve 
terminations  there.  When  a  lot  of  soldiers  are  sud- 
denly quartered,  billeted  in  a  town,  it  is  a  painful 
process.  There  is  pain  in  having  defence  come  to 
your  city.  There  is  pain  in  having  defence  come  to 
your  finger. 

All  of  these  S3miptoms,  which  we  are  apt  to  hate 
and  to  think  of  as  misfortunes,  we  should  realize  are 
the  thing  which  saves  us  from  very  serious  iflness. 
Suppose  these  things  did  not  happen.  Following  out 
the  metaphor,  if  it  were  not  for  these  defences  the 


NATURE'S  CURE  OF  DISEASE      137 

enemy  would  penetrate  into  the  whole  body  and  we 
should  have  blood  poisoning.  It  is  because  this  local 
heat,  redness,  swelling,  pain,  appears  at  the  point 
where  bacteria  are  attacking  us,  that  they  do  not 
penetrate  the  whole  body  with  a  septicemiay  which  is 
one  of  the  most  dangerous  of  all  diseases.  So  while 
suffering  what  we  must  suffer,  we  ought  to  be  glad 
of  all  that  nature  is  doing,  because  if  she  neglected  it 
the  consequences  would  be  very  serious  to  us. 

But  we  may  ask,  "  If  this  is  true,  where  do  medi- 
cine and  surgery  come  in?  Why  do  they  ever  inter- 
fere if  nature  is  so  very  wise?"  Because  nature  over- 
does the  thing  every  now  and  then.  Nature  is  first 
enormously  wise  and  then  a  httle  blind.  In  another 
example  I  can  bring  this  out  a  httle  better.  You 
have  sprained  your  knee  and  the  knee  gets  very  stiff. 
That  in  itself  is  good;  it  is  a  defencive  reaction.  The 
stiffness  is  like  a  splint.  The  knee  ought  to  be  kept 
quiet.  So  far  so  good.  But  nature  overdoes  the  thing. 
The  knee  ought  to  be  kept  quiet,  but  for  how  long? 
We  will  say  three  days  more  or  less,  according  to  the 
severity  of  the  injury.  Then  you  have  to  fight  nature 
which  stiffens  the  knee  too  much.  You  have  to  fight 
it  by  the  use  of  the  knee,  by  walking  or  by  massage, 
which  is  not,  however,  so  good  as  walking.  If  we 
respect  blindly  what  nature  does  in  stiffening  the 
knee  even  to  the  exclusion  of  nature's  other  func- 
tions, such  as  walking,  then  the  knee  will  get  worse. 
One  of  the  greatest  improvements  in  the  modern 
treatment  of  sprains,  is  that  we  no  longer  keep  the 


138  SOCIAL  WORK 

patient  in  bed  and  put  plaster  of  Paris  on,  which 
makes  the  sprain  last  for  months  sometimes;  but  we 
let  him  walk  at  once  on  the  sprained  ankle,  whereby 
the  attempts  of  nature  to  cure  by  stiffening  are  not 
carried  too  far. 

Another  example  of  how  nature  overdoes  things  is 
in  the  formation  of  scar  tissue.  If  a  scar  did  not  form 
to  close  the  wound,  the  wound  would  remain  open. 
Hence  the  scar  is  vastly  better  than  nothing.  But 
scar  tissue  is  never  as  good  as  the  original  tissue. 
One  of  its  known  ill  results  is  contraction,  so  that  a 
scar  on  the  hand  or  on  the  neck  often  draws  the  part 
out  of  place.  Then  we  have  to  fight  nature.  We  have 
to  go  against  the  workings  of  nature  by  surgery,  in 
order  to  get  the  person  right. 

In  suppurative  disease,  such  as  appendicitis,  it  is 
often  difficult  to  decide  when  nature  is  doing  better 
than  we  can  do,  and  when  we  can  do  better  than  na- 
ture. The  appendix  is  a  hollow  tube  the  size  of  one's 
little  finger,  and  hangs  off  from  one  part  of  the  large 
bowel.  When  it  gets  inflamed  nature  at  once  begins 
the  defences  which  I  have  described  in  the  lung, 
namely,  the  walhng-off  process,  which  tends  to  make 
the  bacteria  harmless.  There  is  danger  that  they 
will  spread  from  the  neighborhood  of  the  appendix 
and  produce  a  very  dangerous  disease,  general  peri- 
tonitis. Hence  nature  begins  to  glue  around  the  ap- 
pendix the  adjacent  parts  of  the  bowel  and  anything 
else  at  hand.  This  generally  makes  it  harmless.  Most 
of  us  physicians  now  believe  that  the  great  majority 


NATURE'S  CURE  OF  DISEASE      139 

of  cases  of  appendicitis  cure  themselves,  and  that 
still  more  would  cure  themselves  if  given  a  chance. 
On  the  other  hand,  there  are  cases  in  which  nature 
does  not  do  her  work  rightly.  Then  if  the  surgeon 
did  not  interfere  the  person  would  die.  That  is  why 
medical  and  surgical  judgment,  the  particular,  mi- 
nute, individual  study  of  the  person  from  hour  to 
hour,  makes  the  difference  between  right  and  wrong 
treatment.  The  surgeon  who  operates  every  time 
he  makes  a  diagnosis  of  appendicitis,  or  who  says  he 
will  never  operate,  is  just  as  wrong  as  the  person  who 
gives  money  the  first  time  he  sees  a  case,  or  who  never 
gives  money.  But  most  surgeons  are  wiser  than  that. 
I  hope  through  these  illustrations  to  make  it  clear 
that  nature  generally  cures  disease.  When  she  does 
not,  it  is  generally  incurable.  There  is  a  small  re- 
siduum left  for  the  doctor.  We  have  a  function  as 
physicians  or  nurses.  We  have  a  function,  and  that 
function  is  intermediate  between  two  extremes.  In 
disease  or  in  other  misfortune,  there  are  three  types 
of  fortune,  two  extremes  and  a  mean:  (1)  The  people 
who  will  get  out  of  their  troubles  whatever  you  do, 
get  out  of  their  misfortunes,  rally  to  meet  their 
griefs,  pull  themselves  out  of  financial  difficulties, 
get  over  their  disease.  Then  (2)  there  are  people  on 
the  other  side,  who  will  die  whatever  you  do.  Some 
cases  of  pneumonia,  for  instance,  seem  to  be  doomed 
from  the  start.  It  is  the  same  with  many  other  cases 
of  disease  and  with  some  people's  misfortunes.  We 
have  to  face  the  fact  in  social  work  that  there  are 


140  SOCIAL  WORK 

many  people  whose  mental  twists  and  agonies  we 
cannot  help  in  the  least,  and  many  people  who  will 
be  in  money  difficulties  as  long  as  they  Hve.  But  (3), 
intermediate  between  these  two  extremes — and  our 
happiness  and  our  success  depend  on  our  finding 
that  group  —  are  those  cases  where  what  we  do 
makes  the  difference  between  success  and  failure. 
This  triple  division  indicates  a  point  of  view  which 
makes,  not  only  for  individual  understanding  of  the 
situation,  but  for  practical  success. 

Take  the  case  of  those  maimed  by  war  or  accident. 
There  are  three  classes  of  them:  first,  the  people  who 
will  get  back  their  jobs  and  get  back  into  industry 
unaided;  they  are  probably  the  majority.  Then  the 
people  who  cannot  be  put  back  by  any  process. 
Finally,  there  is  the  rather  small  intermediate  class 
who,  with  our  help,  with  a  little  extra  education, 
with  a  hand  in  the  back,  will  get  back  into  work,  but 
who  never  would  succeed,  humanly  speaking,  with- 
out our  help. 

So  it  is  in  disease.  The  vast  majority  of  diseases 
get  well  without  any  help  from  anybody,  and  that  is 
the  thing  we  must  teach  most  often  and  to  most  peo- 
ple, in  season  and  out  of  season.  In  our  day  and  gen- 
eration few  people  get  a  chance  of  observing  that 
fact,  because  somebody  comes  along  and  gives  them 
a  drug.  And  unless  one  has  seen  people  get  well  with- 
out any  drugs,  one  continues  to  believe  that  it  was 
the  last  drug  given  that  cured  every  case  of  illness 
one  has  known  to  get  well.  On  the  other  hand,  the 


NATURE'S  CURE  OF  DISEASE      141 

majority  of  illnesses  that  do  not  get  well  without 
drugs  will  not  get  well  at  all.  I  have  mentioned  be- 
fore the  figures  which  seem  approximately  true  in 
relation  to  the  cure  of  disease  by  drugs.  Drugs  will 
cure  about  six  or  eight  diseases  out  of  about  one  hun- 
dred and  fifty  diseases  known  to  science.  Anybody 
who  fails  to  give  a  drug  for  one  of  those  six  or  eight 
diseases  is  criminally  negligent.  We  should  press  that 
drug  upon  the  patient.  I  do  not  want  anybody  to 
think  that  I  do  not  beheve  in  drugs.  I  beheve  in 
them  tremendously,  in  the  particular  cases  where 
they  are  of  use.  But  I  do  not  stand  for  the  habit  of 
bolstering  up  people's  beliefs  that  we  have  drugs  all 
ready  to  cure  most  diseases. 

I  think  the  future  of  cure  by  drugs  is  very  hopeful. 
I  do  not  feel  hopeless  of  our  discovering  drugs  for  the 
one  hundred  and  forty-two  out  of  one  hundred  and 
fifty  diseases  which  we  still  cannot  cure.  But  if  we 
falsely  suppose  that  we  have  a  cure  already,  we  do 
not  hustle  around  to  get  it.  It  is  not  until  we  realize 
that  we  have  not  a  cure  already,  that  we  do  hustle 
around  to  get  it.  It  is  not  until  we  realize  that  we  are 
now  very  helpless  in  medicine  that  we  shall  labor  in 
a  way  to  become  less  so.  At  present  the  best  that  we 
can  do  for  most  patients  is  to  explain  what  the  trou- 
ble is,  let  them  know  what  is  going  to  happen,  to 
preach  some  hygiene,  and  above  all  to  make  them 
realize  that  we  care  and  suffer  with  them.  That  is  the 
essence  of  medical  work  and  of  the  social  assistant's 
work  in  the  dispensary  and  ui  the  home. 


142  SOCIAL  WORK 

Industrial  disease 

Industrial  disease  is  a  phrase  we  have  heard  much 
in  the  last  ten  or  fifteen  years,  meaning  that  diseases 
are  caused  —  some  of  them  —  by  the  conditions  to 
which  people  are  exposed  in  industry.  A  great  deal 
of  indignation,  some  of  it  fruitful,  much  of  it  harm- 
ful, has  been  aroused  against  employers  and  against 
the  whole  system  of  industry — because  we  have  now 
recognized  the  fact  of  industrial  disease.  Employers 
in  the  past  have  been  more  interested  in  their  ma- 
chinery than  in  their  human  help.  That  is  not  only 
bad,  but  very  stupid.  Most  of  us  beheve  that  because 
it  is  stupid  it  is  not  likely  to  continue  indefinitely. 

But  aside  from  all  these  matters  of  controversy, 
there  is  one  important  distinction  to  make  at  the 
start,  (a)  Industrial  disease  in  the  narrow,  strict 
sense,  i.e.,  something  produced  by  the  industry, 
something  which  would  never  have  occurred  in  any 
form  if  the  person  had  not  been  in  that  industry. 
(b)  Disease  affected,  modified,  in  some  way  by  in- 
dustry, but  due  in  part  to  other  causes. 

There  are  very  few  clear-cut  and  common  indus- 
trial diseases.  Lead  poisoning  is  almost  the  only  one. 
Disease  due  to  the  inhalation  or  swallowing  of  other 
poisons  and  the  penetration  through  the  skin  or  irri- 
tation of  the  skin  by  definite  poisons  are  real  dan- 
gers, but  not  common.  More  common,  more  difiicult 
to  deal  with,  and  therefore  more  within  the  province 
of  the  social  worker,  are  the  diseases  in  which  in- 


NATURE'S  CURE  OF  DISEASE      143 

dustry  is  only  one  factor  in  the  complicated  skein  of 
causes.  Take  such  matters  as  exposure  to  unusual 
heat  or  cold,  unusual  humidity  or  dryness  in  indus- 
try—  very  common  conditions;  or  still  more,  ex- 
posure to  unusual  strain  and  hurry  from  what  we 
call  "speeding-up"  or  from  the  piece-work  system.  I 
do  not  think  there  is  any  good  evidence  that  those 
things  produce  any  single  disease.  I  think  there  is  ex- 
cellent evidence  that  they  often  dip  the  scale  whereby 
a  person  who  has  been  in  equilibrium,  able  to  get 
along  with  his  outside  troubles,  and  to  keep  his  bal- 
ance, is  finally  knocked  down  into  disease. 

A  person  has  tuberculosis.  One  of  the  favorite 
tricks  of  unscrupulous  political  orators  is  to  say, 
"Look  at  all  that  tuberculosis  due  to  the  greed  and 
the  cruelty  of  employers!"  Bad  conditions  of  indus- 
try are  doubtless  a  factor  in  the  production  of  tuber- 
culosis, but  we  must  realize  how  many  and  impor- 
tant the  other  factors  are.  The  eight  or  ten  hours  a 
person  spends  in  industry  is  often  a  small  factor  in 
producing  his  ill  health,  compared  to  the  fourteen  or 
sixteen  hours  he  spends  outside  the  industry.  Hence 
if  we  are  to  understand  the  diseases  of  workmen  we 
must  investigate  these  hours  just  as  carefully  as 
those  in  the  factory.  That  is  what  we  ordinarily 
omit.  We  find  so  many  cases  of  tuberculosis  in  a 
given  industry,  and  we  say,  "Ah,  then,  these  cases 
are  due  to  the  hardships  of  that  industry." 

In  refutation  of  this  idea  there  is  one  more  dogma 
packed  for  transportation,  which  I  should  like  to 


144  SOCIAL  WORK 

offer  in  the  form  of  a  logical  fallacy  which  the  medi- 
aeval logicians  put  down  in  Latin  terms:  "Post  hoc, 
ergo  propter  hoc'':  "After  this,  therefore  because  of 
this."  One  of  our  duties  as  doctors  and  social  work- 
ers is  to  combat  fallacies,  to  teach  people  to  think 
straight  instead  of  crooked  about  their  ill  health  and 
their  other  troubles.  When  thus  occcupied,  a  large 
part  of  our  labors  will  consist  in  trying  to  overcome 
the  popular  fallacy  quoted  above.  "You  went  into  a 
particular  industry  and  you  had  tuberculosis:  there- 
fore you  had  tuberculosis  because  you  went  into  that 
industry."  "You  had  a  given  disease  and  you  took  a 
certain  remedy :  you  got  better,  therefore  the  remedy 
cured  the  disease."  So  the  superstitions  flourish.  I  do 
not  believe  it  is  easy  for  any  of  us  to  extricate  our- 
selves from  that  particular  fallacy,  but  we  must  try. 
In  industrial  disease  we  have  the  causative  factor 
of  industrial  hardship  intimately  mixed  up  with 
other  factors.  One  of  my  colleagues.  Dr.  Roger  I. 
Lee,  of  whose  book  I  have  already  spoken,  investi- 
gated, in  our  clinic  at  the  Massachusetts  General 
Hospital,  the  cases  of  one  hundred  young  working- 
girls,  factory  employees,  who  either  had  tuberculo- 
sis or  were  suspected  of  tuberculosis  —  were  in  what 
is  wrongly  called  the  "pre-tubercular  stage,"  when 
the  doctor  has  not  made  up  his  mind  whether  the  pa- 
tient has  tuberculosis  or  not.  He  studied  these  cases, 
as  people  ought  to  study  them,  always  in  proper  co- 
operation with  a  socialworker.  He  made  his  own 
careful  observations  in  the  dispensary.  Then  he  em- 


NATURE'S  CURE  OF  DISEASE      145 

ployed  a  social  worker  to  study  the  girls  in  the  home 
and  outside  the  home,  following  up  in  their  lives 
and  personahties  the  tangles  of  disease.  His  total 
result  was  that  he  could  not  say  in  any  given  case 
that  industry  had  produced  a  single  one  of  the  dis- 
eases which  he  found,  though  he  was  not  willing 
to  swear  that  it  had  not  done  so.  He  found  that  a 
certain  number  of  these  girls,  in  their  perfectly  nat- 
ural search  for  recreation,  were  running  around 
the  streets  or  elsewhere  until  the  small  hours  of  the 
morning.  That  is  an  obvious  factor  in  producing  a 
diseased  state.  It  is  not  that  we  want  to  blame  peo- 
ple for  seeking  recreation;  but  the  results  cannot 
also  serve  as  evidence  of  the  harm  done  by  industry, 
except  in  a  very  wide  sense  in  which  we  might  say 
that  industry  does  harm  because  it  dose  not  provide 
for  recreation,  which  is,  I  think,  an  extreme  view. 

Dr.  Lee's  social  assistants  found  that  a  good  many 
of  these  girls  had  no  habits  of  eating.  It  was  not  that 
their  habits  were  so  bad,  but  that  they  had  none  of 
any  kind.  Sometimes  they  ate  very  well  and  some- 
times they  did  not.  Then  he  found,  as  of  course  one 
would  know  that  he  would,  the  psychical  factors  in 
many  of  these  cases  —  their  love  affairs  and  other 
worries  which  were  often  much  more  deleterious  to 
their  health  than  their  habits  of  sleep  or  food  or  even 
their  industrial  conditions. 

When,  therefore,  one  tries  to  consider  industrial 
disease,  one  must  realize  how  complex  a  thing  it  is, 
how  essential  it  is  to  go  beyond  the  inspection  of  the 


146  SOCIAL  WORK 

factory  and  to  study  all  the  conditions  of  the  lives  of 
the  people  that  one  is  concerned  with. 

In  a  big  Western  American  town  that  I  visited  re- 
cently, where  the  automobile  tire  industry  was  em- 
ploying some  fifty  thousand  hands  in  factories,  the 
most  obvious  cause  for  ill  health  was  the  tremendous 
congestion  in  that  town,  and  as  a  result  the  fearful 
state  of  the  available  lodgings.  Again  most  of  the 
factory  hands  were  foreigners;  very  few  of  them 
spoke  English;  they  were  wholly  dislocated  from 
normal  family  life,  from  any  connection  with  their 
own  countries  and  from  their  own  previous  interests. 
That  is  in  itself  a  dangerous  condition  for  hygiene 
as  well  as  for  morals.  Factors  like  that  must  be 
taken  account  of  when  we  want  to  help  anj^body  to 
get  free  of  the  troubles,  the  fatigue  or  strain  or  de- 
bility, which  we  are  apt  to  attribute  to  industry. 

We  are  keen,  and  rightly  keen,  to  find  and  to  abol- 
ish poisons,  such  as  lead,  such  as  phosphorus,  such 
as  carbon  monoxide.  We  ought  to  be  keen  to  study 
poisons  of  that  kind,  and  more  interest  has  lately 
been  concentrated  upon  them  through  war  work 
and  war  industries  than  ever  before.  But  there  are 
moral  poisons  which  we  do  not  notice  or  mention. 
Monotony,  for  instance.  Monotony  is  not  altogether 
a  horrible  or  hateful  fact.  Most  of  us  want  some  mo- 
notony in  our  day.  We  want  a  rhythm  and  a  certain 
recurrence  in  it,  whereby  our  work  comes  to  seem 
famihar  to  us  and  we  do  somewhere  near  the  same 
thing  each  day.  There  is  rest  in  that.  But  how  much 


NATURE'S  CURE  OF  DISEASE      147 

we  need  is  individual;  the  dose  of  monotony,  the 
amount  that  is  good  for  you  and  for  me  is  hmited. 
People  often  get  too  much,  and  when  they  get  too 
much,  then  it  is  a  moral  poison.  One  of  the  most  ap- 
paUing  things,  I  think,  is  its  effect  upon  the  mind.  I 
have  often  wondered  whether  I  ever  had  or  ever 
would  have  any  mind  again,  when  I  have  come  to 
the  end  of  such  a  day.  Any  one  of  us,  of  course,  can 
duplicate  that  experience,  and  it  certainly  ought  to 
make  us  think  hard  about  the  lives  of  manual  work- 
ers whose  days  are  quite  likely  to  be  like  that  right 
along.  At  the  end  of  such  a  monotonous  day  a  person 
may  be  pretty  reckless,  may  feel  that  he  does  not 
care  what  happens  to  him.  I  have  met  that  in  a  great 
many  histories.  It  is  not  so  much  that  monotony 
makes  machines  of  them  as  that  it  makes  wild  ani- 
mals of  them. 

Another  moral  poisoning  is  the  sense  of  injustice,  a 
sense  that  it  is  not  right  that  somebody  else,  whom 
the  Lord  did  not  make  very  different,  has  so  much 
more  of  money  and  opportunity  and  happiness  than 
the  person  himself  has.  It  is  altogether  a  secondary 
question  to  discuss  whether  that  is  true  or  not.  I  do 
not  myself  beheve  that  the  rich  are  any  happier  than 
the  poor.  On  the  whole,  I  think  the  evils  of  money 
are  just  as  great  as  the  evils  of  poverty.  But  the 
sense  of  injustice  is  often  just  as  real  even  though 
the  reasoning  on  which  it  is  based  is  wrong;  and  the 
sense  of  injustice  is  a  moral  poison  which  breaks 
down  health  and  spoils  happiness. 


148  SOCIAL  WORK 

Can  we  do  anything  about  it?  Sometimes.  By  go- 
ing over  the  details  of  people's  lives,  by  telling  them 
stories  of  other  people's  lives,  by  confessing  a  great 
deal  about  our  own  life,  we  can  help  people  to  see 
things  differently.  When  I  was  speaking  of  pains  in 
the  region  of  the  heart  I  said  that  one  of  the  most 
important  things  that  one  could  learn  is  to  distin- 
guish between  the  pain  and  what  we  think  of  it.  The 
pain  often  cannot  be  changed,  but  our  interpreta- 
tion of  it  often  can.  The  patient  often  suffers  chiefly 
from  what  he  thinks  of  the  pain,  and  when  he  knows 
that  the  pain  is  not  due  to  heart  disease  and  that  he 
probably  will  live  to  be  a  hundred,  that  particular 
form  of  suffering  leaves  him.  So  in  this  matter  of  the 
sense  of  injustice,  the  causes  for  suffering  may  be 
unchangeable,  but  if  we  can  change  the  patient's 
point  of  view  we  may  help  him  a  great  deal. 

A  greater  evil,  I  think,  than  any  I  have  men- 
tioned, and  one  that  we  are  almost  powerless  to  at- 
tack, is  lowered  sex  standards,  which  come  from  the 
crowding  of  people  of  all  ages  and  both  sexes  into  in- 
dustry. As  in  the  housing  problem,  it  is  the  moral 
rather  than  the  physical  side  of  crowding  that  is 
most  serious. 

That  is  why  the  visiting  part  of  social  work  seems 
to  me  so  much  the  most  important.  The  important 
part  is  what  we  hope  goes  on  in  home  visits,  when 
the  social  assistant  meets  people  where  they  will 
talk  as  of  course  they  cannot  talk  in  the  dispensary. 


PART  II 

Social  Treatment 


CHAPTER  VIII 

SAMPLES  OF  SOCIAL  THERAPEUTICS 

1.  Order  in  social  treatment 

The  principles  of  linkage  embodied  in  the  work  of 
the  home  visitor,  in  her  cooperation  with  doctors 
and  other  social  workers,  and  in  good  history-taking 
which  avoids  the  fallacies  of  the  catastrophic  point 
of  view,  take  on  a  little  more  impressiveness  when 
we  consider  what  a  widely  general  law  that  "hnk- 
ing-up"  law  is.  It  is  the  essence  of  science;  indeed,  it 
is  the  essence  of  things  still  wider,  for  it  is  the  es- 
sence of  order. 

There  is  an  old  phrase  that  "order  is  heaven's 
first  law."  It  certainly  is  an  impressively  universal 
principle.  How  universal  this  linking-up  process  is, 
and  how  it  appHes  to  all  possible  situations  medi- 
cal and  social,  can  be  made  to  stick  in  our  memories 
by  the  phrase,  "In  view  of  this,  what  next?"  This  is 
a  prosaic  and  unimpressive-sounding  dictum;  but 
with  some  trivial  and  some  important  illustrations  I 
can  show  that  it  is  really  useful. 

1.  A  terrier  dog  is  watching  a  rat-hole:  in  view  of 
this,  what  next?  —  a  question  full  of  importance  for 
the  dog  and  for  the  rat. 

2.  A  cobbler  is  working  on  his  shoe:  in  view  of 
what  he  has  already  done  upon  that  shoe,  what  shall 
he  do  next?  The  value  of  the  shoe,  the  value  of  the 


152  SOCIAL  WORK 

cobbler's  working  time,  depend  upon  his  seeing  truly, 
and  then,  in  view  of  that  vision,  doing  whatever  is 
next  called  for  by  the  conditions  of  the  shoe  which 
he  is  dealing  with. 

3.  As  we  go  down  the  bill  of  fare  of  a  restaurant, 
we  say,  "In  view  of  what  I  have  eaten,  what 
next?"  Presumably  there  is  a  method,  an  order  in 
our  madness. 

4.  We  may  have  known,  in  the  course  of  our  lives, 
a  few  people  who,  when  we  ask  them  a  question, 
think  before  they  answer.  These  are  the  people  who 
habitually  say  to  themselves,  "In  view  of  this  ques- 
tion and  of  the  truth  which  I  should  speak,  what 
words  should  issue  from  my  lips?" 

5.  The  whole  science  of  logic  is  the  science  of  see- 
ing truly:  in  view  of  certain  premises,  what  is  next? 
What  follows  and  must  follow,  if  we  are  to  be  logical. 

6.  Anybody  who  has  got  to  a  certain  point  in  his 
profession  says,  "In  view  of  my  successes  and  my 
failures  thus  far,  what  is  the  next  thing  for  me  to 
do?"  One  can  say  the  same,  and  I  imagine  that  most 
people  have  often  said  it  to  themselves,  in  relation 
to  friendships:  in  view  of  my  present  affection  or 
dislike  for  that  person,  what  next?  We  have  come 
through  the  world's  most  gigantic  war:  in  view  of 
this,  what  next? 

7.  I  tried  to  exemplify  this  principle  also  in  our  med- 
ical and  social  history-taking.  Our  histories  should 
be  orderly.  There  is  a  thing  that  rightly  comes  first 
and  a  thing  that,  in  view  of  this,  should  come  next. 


SOCIAL  THERAPEUTICS  153 

8.  When  the  musician  composes  or  plays,  he  is 
guided  in  the  writing-out  or  in  the  instrumental  ex- 
pression of  his  musical  idea  by  his  consciousness  of 
the  whole  piece  —  what  is  done  and  still  to  be  done. 
"In  view  of  this  whole,"  he  asks  himself,  "what 
notes  come  next?" 

9.  When  a  man  prays  he  says  to  himself,  "In 
view  of  my  sins  and  of  God,  what  next?  " 

It  appears,  then,  that  the  most  trivial  and  the 
highest  things  that  go  through  the  human  mind,  if 
they  go  right,  follow  that  formula,  because  it  is  sim- 
ply a  way  of  putting  truth  in  order,  and  because 
order  is  as  fundamental  to  a  human  mind  that  is 
working  right  and  not  wi'ong,  as  anything  can  be. 
The  catastrophic  point  of  view,  on  the  other  hand, 
is  the  point  of  view  of  disorder,  the  behef  that  things 
happen  "as  the  result  of  accident,"  come  upon  us 
without  order,  were  never  in  view  beforehand,  oc- 
curred for  no  known  reason. 

The  principle  of  order  is  also  closely  knit  to  the 
principle  of  independence  or  integrity,  which  we 
want  to  achieve  in  social  work  when  we  give.  Physi- 
cally we  want  the  person  to  be  independent,  not  de- 
pending upon  a  drug,  not  needing  to  be  jacked  up  by 
a  stimulant,  not  dependent  as  a  sick  man  is  depend- 
ent, on  nursing,  special  diets,  and  long  rests.  In  the 
economic  field  we  try  to  avoid  making  a  person  de- 
pend on  a  crutch,  a  support,  a  pension,  which  atro- 
phies his  economic  powers  instead  of  developing 
them.  At  least  we  desire  not  to  weaken  them.  We 


154  SOCIAL  WORK 

want  to  give  and  build,  to  give  something  that  will 
go  on  by  itself  to  make  him  independent  of  us. 

But  independence  is  not  altogether  a  good  phrase. 
No  human  being,  linked  up  in  a  world-order  as  we 
all  are,  is  ever  independent.  What  we  mean  by  that 
not  altogether  satisfactory  phrase  is  that  we  want 
to  be  dependent  only  upon  something  that  we  can 
rely  upon,  only  upon  permanent,  central,  orderly 
powers  of  the  universe.  Physical  independence  does 
not  mean  independence  of  food  or  of  rest;  one  soon 
comes  to  the  end  of  his  tether  if  one  attempts  such 
independence.  Dependence  means  hanging.  We 
must  all  hang.  But  we  want  to  hang  upon  something 
that  will  not  let  us  down,  upon  food,  air,  warmth, 
exercise,  rest,  such  as  are  always  available  in  an 
orderly  hfe,  or  should  be. 

So  in  the  economic  field,  no  man  is  economically 
independent  or  ever  will  be.  But  we  want  his  powers 
knit  into  an  orderly  system  that  is  not  dependent 
upon  a  protective  tariff,  on  somebody's  whim  who 
pays  his  salary,  or  on  political  "pull."  We  want  peo- 
ple to  be  independent  in  the  sense  that  they  get  their 
living  by  connection  with  a  well-ordered  economic 
system.  Even  then,  of  course,  we  are  not  independ- 
ent. A  planet  may  run  into  us  and  we  shall  then  be 
wrecked  in  spite  of  the  fact  that  we  are  not  depend- 
ent upon  charity  or  a  protective  tariff. 

Obviously  literal  independence  is  also  impossible 
in  moral  and  personal  relations.  We  are  never  inde- 
pendent of  society,  never  capable  of  going  it  alone. 


SOCIAL  THERAPEUTICS  155 

The  only  question  is,  On  what  do  we  depend?  Do 
we  depend  on  one  person,  or  one  particular  kind  of 
entertainment  or  stimulation?  Or  can  we  find  our 
food  in  any  of  a  vast  number  of  places  and  persons 
which  in  the  natural  order  are  fairly  sure  to  be  avail- 
able? Or  in  the  absence  of  all  finite  persons  can  we 
find  our  food  in  God?  That  is  the  fundamental  ques- 
tion in  relation  to  personal  independence.  Its  an- 
swer states  the  degree  in  which  our  personal  history 
is  orderly  and  not  catastrophic. 

If  one  is  habitually  trying  to  order  his  own  life  in 
this  way,  the  principles  by  which  he  lives  will  guide 
his  attempts  at  social  treatment  and  give  him  con- 
tinuity and  steadiness. 

2.  Presence  of  mind  in  social  treatment 

All  our  diagnostic  duties,  whether  as  doctor  or 
social  worker,  are  part  of  our  search  for  truth,  physi- 
cal, economic,  mental,  and  moral,  as  the  basis  for 
medical-social  treatment.  I  have  used  again  and 
again  the  figure  of  chains,  each  of  them  starting  with 
the  individual's  present  misfortune,  need,  or  sorrow, 
as  a  central  link,  and  radiating  in  different  directions 
as  we  trace  out  the  relevant  physical  and  economic 
facts,  the  chain  of  the  patient's  relationships  to  fam- 
ily and  friends,  some  of  whom  he  is  apt  to  forget, 
and  finally  the  chain  of  mental  and  moral  causes 
which  lead  up  to  the  present  moment.  I  believe  in 
that  method  with  all  my  heart.  I  also  believe  it  can 
be  employed  so  one-sidedly,  so  exclusively,  as  to 


156  SOCIAL  WORK 

spoil  social  work.  The  criticism  of  social  work  which 
recurs  most  often  and  most  justly,  I  think,  is  that 
we  are  not  human  enough,  not  big  enough  people  to 
do  social  work,  that  we  have  not  vision,  that  we  get 
into  mechanical  and  routine  methods  which  spoil 
the  whole  adventure.  I  know  that  this  is  true.  We 
fail  because  it  is  difficult  for  us  to  drive  in  span  two 
strongly  contrasted  ideals  only  one  of  which  I  have 
yet  laid  great  stress  on.  Truth  and  the  following 
out  of  the  links  of  truth,  physical,  economic,  etc., 
is  a  process  which  we  might  call  looking  for  the  back- 
ground of  the  fact  that  presents  itself  close  to  you. 
We  need  to  see  that  background.  We  must  not  get 
our  perspective  distorted.  It  is  the  doctor's  common- 
est fault,  that  he  sees  only  the  disease  that  is  just 
now  before  him,  and  nothing  of  its  "background," 
economic,  mental,  or  moral.  Hence  he  does  not  make 
a  fundamental  diagnosis  or  prescribe  fundamental 
treatment. 

We  need  in  our  dispensary  work  to  find  truth.  Yes; 
but  we  need  io  find  Joy  also  in  our  work;  we  need  to 
see  the  foreground.  We  do  not  want  to  have  attached 
to  us  the  stigma  and  the  weakness  which  we  think  of 
in  professional  work.  We  are  accustomed  to  beheve 
that  professional  philanthropists  find  no  joy  in  their 
work,  which  they  do  as  a  matter  of  routine,  for  pay, 
without  vision  and  without  a  sense  of  the  unexpected 
and  momentary  values  which  are  precious. 

The  process  of  tracing  chains,  of  looking  off  and 
away  from  the  patient's  present  pain,  sorrow  or  pov- 


SOCIAL  THERAPEUTICS  157 

erty  for  its  causes  and  relations,  tends  to  make  us 
look  over  the  head  of  the  present  fact.  We  all  know 
people  who  always  look  over  our  heads  when  they 
talk,  and  we  know  how  little  they  get  into  touch 
with  us.  We  must  not  stare  into  the  physical,  eco- 
nomic, or  mental  background  so  constantly  or  so 
fixedly  that  we  cannot  see  the  present  fact  before  us. 
That  is  preoccupation.  I  have  often  accused  myself 
and  my  assistants  of  going  about  their  work  with  a 
care-worn  air,  because  we  are  thinking  so  much  of 
the  fine,  helpful  plans  which  we  are  making  and  the 
truths  which  we  are  going  to  discover,  or  of  bother- 
some details  which  we  have  not  got  round  to  finish- 
ing up.  But  we  shall  do  no  good  in  the  long  run 
unless  we  enjoy  our  work.  There  may  be  some  pro- 
fessions where  a  man  or  a  woman  can  be  of  use 
who  does  not  draw  joy  from  work,  but  certainly 
social  work  is  not  such  a  profession.  We  have  with 
Stevenson  the  duty  of  happiness: 

"  If  I  have  faltered  more  or  less 
In  my  great  task  of  happiness," 

—  What  are  we  to  do?  We  must  wake  up  — 

"Lord,  Thy  most  pointed  pleasure  take 
And  stab  my  spirit  broad  awake." 

We  are  not  awake.  We  are  half  asleep,  dreaming 
over  our  plans,  our  worries,  our  visions.  That  is  why 
we  are  preoccupied;  looking  over  the  head  of  the  im- 
mediate fact,  we  miss  the  amazing  beauty  of  face, 
word,  and  character  tempered  and  enhanced  by  suf- 
fering. 


158  SOCIAL  WORK 

Much  as  I  hate  the  fault  of  never  going  beyond 
the  fact  that  we  see  before  us,  I  hate  just  as  much 
the  opposite  error  of  not  getting  the  full  vision  of  the 
foreground.  We  ought  always  to  be  able  to  feel,  at 
the  end  of  any  single  home  visit,  that  we  have  done 
something,  accompUshed  something.  Well:  one  of 
the  things  that  we  must  make  every  effort  to  accom- 
plish, and  to  feel  ourselves  a  failure  if  we  have  not 
accomplished,  is  to  find  and  to  give  pleasure,  to  en- 
joy ourselves,  and  if  possible  to  give  a  httle  courage. 
The  little  embellishments  of  our  work,  the  smile,  the 
tone  of  voice,  the  jokes  and  courtesies  of  our  fleeting 
contacts  with  individual  patients,  should  be  just  as 
precious  to  us  as  any  of  our  far-reaching  plans  and 
deep-plunging  attempts  to  study  into  cases.  How 
poignantly,  how  intensely  Christ  put  this  to  us  in 
saying  that  inasmuch  as  we  did  any  good  thing  unto 
the  least  of  his  brethren  we  did  it  unto  Him!  I  be- 
lieve that  He  meant  this  not  only  of  human  beings, 
but  of  days,  of  moments.  The  least  of  these  oppor- 
tunities is  infinitely  precious  and  we  are  making  a 
grievous  mistake  if  we  do  not  take  it  so. 

I  have  known  a  few  social  assistants  who  make 
each  little  deed  and  each  little  moment  a  perfect 
work  of  art  in  itself.  Art  at  its  best  this  work  is.  It 
was  my  greatest  single  experience  in  1917-18  to  ad- 
mire the  French  art  for  finding  joy  in  little  things, 
and  of  making  beauty  in  little  things.  I  asked  re- 
cently a  group  of  Americans  what  they  had  found 
the  most  admirable  in  their  contact  with  the  French 


SOCIAL  THERAPEUTICS  159 

people.  Everybody  present  had  had  the  experience 
of  finding  in  his  own  hotel  or  pension^  a  femme  de 
chambre  or  some  other  domestic  who,  though  start- 
ing to  work  at  five  o'clock  in  the  morning  and  work- 
ing until  late  at  night,  nevertheless  always  kept  joy 
or  the  appearance  of  joy  in  her  work.  On  the  first 
night  that  I  was  in  Paris  I  went  with  a  friend  to  dine 
at  a  restaurant  very  late.  There  was  but  one  wait- 
ress, who  had  nearly  finished  serving  an  enormous 
number  of  people.  She  ought  to  have  been  near  the 
end  of  her  day's  work,  which  our  arrival  prolonged 
still  more.  But  I  never  can  forget  the  welcoming  look 
and  tone  with  which  she  said  to  us,  "Now  I  shall 
have  the  pleasure  of  serving  you.'* 

We  need  the  artistic  spirit,  the  spirit  of  beauty  in 
social  work.  It  is  not  opposed  to,  but  surely  very 
different  from,  the  spirit  of  science  which  I  have 
been  emphasizing  in  the  earUer  chapters  of  this 
book.  I  must  confess  my  impression  that,  on  the 
whole,  thus  far,  social  work  has  been  ugly.  Social 
workers  have  not  kept  beauty  and  the  sense  of 
beauty  in  the  foreground  of  their  work.  Beauty  and 
joy  always  tend  to  drop  out  in  social  work,  but  this 
must  not  be.  There  is  an  old  story  of  an  inspired  so- 
cial assistant  in  Boston  who  had  been  working  for  a 
long  time  with  a  needy  family  who  were  at  that  time 
much  discouraged.  One  day  she  had  an  idea:  "What 
that  woman  needs  is  a  blue  dress.  She  is  extraordi- 
narily fond  of  that  color.  She  has  not  had  a  new  dress 
for  a  long  time."  And  it  was  true.  She  was  given  a 


160  SOCIAL  WORK 

blue  dress,  and  the  history  of  that  family  afterwards 
began  to  show  signs  of  the  sort  of  change  and  up- 
ward constructive  effort  which  had  long  been  lack- 
ing. We  cannot  neglect  that  sort  of  thing,  slight  or 
sentimental  though  it  may  seem. 

I  remember  another  family  in  which  flowers,  and 
money  spent  on  giving  the  children  a  chance  to 
grow  flowers,  played  a  beneficent  role;  and  still  an- 
other discouraged  family  in  which  a  canary  bird 
seemed  an  essential  element  in  the  social  work  done. 

There  is  something  certainly  very  divine  about 
the  present  moment.  We  shall  never  have  it  again. 
We  are  apt  to  think  that  next  year  we  shall  do 
something  great.  Then,  we  think,  at  last  we  shall 
gather  up  all  the  forces  of  our  soul  and  do  some- 
thing worthy.  But  I  do  not  beUeve  we  can  tefl  our- 
selves too  often  in  social  work  that  now  is  the  time, 
and  that  the  opportunity  of  the  present  moment  is 
priceless. 

Hence,  after  trying  to  exemplify  the  backgrounds 
which  we  ought  to  seek  out  when  a  fellow  being 
comes  to  us  in  trouble,  I  must  now  correct  that  over- 
emphasis by  paying  homage  to  that  state  of  mind 
which  sees  foregrounds.  What  we  want  is  presence  of 
mind — a  very  familiar  and  hackneyed  phrase,  but 
one  which  may  grow  precious  to  us  after  analysis. 
My  complaint  against  the  preoccupied,  solemn  look 
in  the  social  worker's  face  is  that  the  person's  mind 
is  not  there  with  his  fellow  beings;  it  is  aloof  with  his 
own  troubles.  He  is  not  "in  it,"  not  aU  there  on  the 


SOCIAL  THERAPEUTICS  161 

spot.  The  necessity  of  joy  in  one's  work,  and  the 
necessity  of  seeing  the  momentary  and  infinitely 
precious  opportunities,  come  to  the  same  thing.  If 
you  are  "in  it,"  you  get  your  chance.  To  have  suffi- 
cient presence  of  mind  to  seize  one's  chance  is  surely 
the  crucial  act  in  social  work  or  anywhere  else,  for 
that  chance  does  not  recur. 

But  presence  of  mind  connects  itself  with  an  in- 
teresting fact  in  our  grammar  about  the  present 
tense.  The  present  tense,  in  contrast  with  past  and 
future  tenses,  expresses  presence  of  mind,  attention 
to  the  wonder  of  the  moment,  the  opportunity  of 
the  moment.  But  it  also  expresses  a  wholly  different 
thing,  namely,  the  eternal.  Some  languages  have  an 
eternal  tense  and  use  it  about  facts  that  are  not 
present  or  past  or  future.  We  use  the  present  tense 
for  the  eternal.  Two  and  two  make  four.  When? 
Well,  not  of  course  at  ten  minutes  before  twelve  on 
the  11th  of  November,  1918,  more  than  at  any  other 
time.  We  might  just  as  well  use  the  future  tense. 
Two  and  two  always  will  make  four.  But  by  a  pe- 
culiar accident  we  have  hitched  on  to  one  tense  the 
whole  body  of  eternal  truth.  Why  did  we  hitch  the 
eternal  to  the  present  rather  than  to  the  past  or  to  the  fu- 
ture? Because  anirthing  that  we  really  grasp  now,  as 
truth  or  as  joy  or  as  beauty,  anything  that  we  really 
comprehend,  can  be  eternally  ours.  In  the  physical 
sense  it  is  so.  The  electric  light  that  I  am  now  look- 
ing at  and  which  might  be  turned  off  at  any  moment, 
is  eternal,  for  its  vibrations  are  travelling  off  through 


162  SOCIAL  WORK 

space  and  always  will  be.  The  fact  that  those  vibra- 
tions are  going  off  through  the  ether  is  ever  the  same. 
Any  present  fact,  then,  so  far  as  we  realize  its 
truth  or  its  wonder,  is  eternally  ours.  Hence  presence 
of  mind  is  the  quality  needed  in  social  work  to  bal- 
ance the  scientific  habit  which  looks  for  past  and 
future,  for  what  is  not  present.  Investigation  and 
history-taking  must  always  be  completed  by  appre- 
ciation, the  other  half  of  our  mental  life,  which  is 
acutely  conscious  of  the  present  and  therefore  can 
be  conscious  of  eternity. 

I  hope  I  have  not  put  the  contrast  of  science  and 
art  in  social  work  so  sharply  that  it  seems  as  if  one 
must  take  one  extreme  or  the  other.  I  do  not  feel  any 
such  contradiction.  I  believe  that  we  can  get  courage 
for  the  long,  discouraging  search  for  causes  out  of 
the  present  joy  which  we  find  in  speaking  and  Usten- 
ing  to  a  person  now.  On  the  other  hand,  these  mo- 
mentary contacts  are  thin,  capricious,  and  insuffi- 
cient if  we  are  not  also  planning  some  solid  progress 
which  will  give  us  something  to  show  for  it  at  the 
end  of  a  day  or  a  year.  One  of  the  dreary  things 
in  human  beings'  work  is  that  sometimes,  after  a 
month  or  a  year,  they  cannot  see  that  they  have  ac- 
compHshed  anything.  It  is  all  a  mass  of  details.  I  re- 
member a  very  marvellous  social  worker  saying  to 
me,  "  I  do  not  want  to  die  thinking  that  I  have  never 
done  anything  but  case  work."  Case  work  seems  to 
me  as  great  a  thing  as  any  one  can  do.  One  might  as 


SOCIAL  THERAPEUTICS  163 

well  say,  "  I  have  never  done  anything  but  miracles." 
But  I  know  what  she  meant.  She  meant  that  through 
case  work  she  wanted  to  feel  that  there  was  a  thread 
of  continuity  which  ought  to  be  science  or  character 
or  friendship,  a  thread  whereon  something  accumu- 
lates. We  ought  each  year  to  be  able  to  say  and  to 
write  what  we  have  learned,  or  given. 

3.  How  to  give  in  social  treatment 

Social  treatment  is  giving  and  constructing.  We 
want  to  give 

Pleasure 

Beauty 

Money 

Information 

Education 

Courage 
and  to  help  build  the  power  to  get  more  of  each. 

1.  Pleasure.  As  we  want  to  find  pleasure  in  our 
work,  we  surely  want  to  try,  so  far  as  our  human 
capacities  allow  us,  to  give  pleasure,  to  make  people 
feel  comfortable,  to  be  always  so  pohte  to  them  and 
finally  so  fond  of  them,  that  they  will  enjoy  the  mo- 
mentary contact  no  matter  what  it  is  about.  As  I 
look  back  over  medical  work  of  twenty-five  years, 
I  should  say  that  in  most  of  my  cases  I  have  failed 
from  the  medical  point  of  view.  Yet  in  a  great  many 
of  those  failures  I  can  see  some  redeeming  feature 
because  of  the  friendships  that  the  patient  and  I 
built  while  I  was  failing  in  my  medical  job. 


164  SOCIAL  WORK 

Such  a  blending  of  success  and  failure  is  the  rule, 
not  the  exception.  We  make  elaborate  social  plans, 
but  we  know  that  many  of  them  are  going  to  fail.  It 
is  humanly  impossible  that  they  should  not  fail.  But 
they  will  not  he  flat  failures  if  along  the  way  we  have 
tried  to  treat  people,  not  as  they  deserve,  but  a  great 
deal  better.  1 

But  when  we  give  pleasure  we  must  try  to  provide 
that  the  stock  shall  go  on.  We  want  to  try  to  build 
in  and  with  the  person  some  capacity  to  get  that 
pleasure  for  himself  after  we  have  gone  out  of  his 
Ufe.  This  is  just  as  true  of  course  of  Beauty  which  we 
surely  want  to  try  to  bring  into  our  patients'  lives, 
and  which  is  one  of  the  things  that  redeems  our  fail- 
ures on  the  other  side  of  social  work.  Even  people 
who  are  dying  sometimes  can  get  great  enjoyment 
of  beauty. 

2.  Money  is,  I  suppose,  on  the  whole,  the  thing 
we  are  asked  for  directly  or  indirectly  most  often  in 
social  work.  If  we  are  not  doing  direct  medical  work, 
if  we  are  not  giving  a  direct  medical  relief  or  trying 
to,  we  are  more  than  hkely  to  be  asked  for  help  in 
the  way  of  money,  clothes,  food,  or  rent.  Surely  no 
one  works  long  in  social  work  who  does  not  find  the 
right  place  to  give  money.  But  I  have  to  go  back  to 
the  figure  already  used,  the  parallelism  of  money 
and  morphine.  A  person  comes  to  us  with  pain  and 

1  Polonius  (showing  out  the  wandering  actors) :  —  My  Lord,  I  will 
use  them  according  to  their  desert. 

Hamlet:  Odd's  bodikia,  man,  much  betterl  Use  every  man  after 
his  desert  and  who  shaJl  'scape  whipping. 


SOCIAL  THERAPEUTICS  165 

begs  for  money  or  its  equivalent  —  direct,  immedi- 
ate relief.  What  makes  us  hesitate  in  the  one  case  is 
the  same  that  makes  us  hesitate  in  the  other.  We 
may  reheve,  yes;  but  have  we  constructed?  In  the 
long  run  we  must  both  construct  and  give,  else  our 
giving  may  be  useless  or  harmful. 

When  can  we  give  money  without  doing  harm? 

In  a  general  way,  when  it  is  not  going  to  lead  to 
the  repetition  of  the  same  demand.  When  are  we 
perfectly  sure  that  we  may  safely  give  morphine?  In 
gall-stone  cohc.  For  it  may  be  weeks,  months,  years, 
perhaps,  before  there  will  be  another  such  attack  of 
cohc.  We  give  morphine  once  only.  The  person  gets 
over  the  attack,  and  does  not  want  morphine  again 
for  months  or  years.  But  if  the  patient's  pain  is 
chronic  or  likely  to  recur  soon  and  frequently,  it  is 
cruel  to  give  morphine,  because  soon  the  patient  will 
have  all  that  pain  again,  and  more  —  the  pain  which 
is  produced  by  morphine  after  it  has  been  taken  a 
little  while.  We  never  can  tell  that  the  pain  suffered 
is  not  wholly  due  to  morphine.  So  the  person's  trou- 
ble after  we  have  given  money  may  be  due  to  the 
money  itself,  ill  used.  We  should  be  able  to  say,  after 
a  careful,  though  not  care-worn  study  of  the  case, 
that  we  know  the  patient's  pecuniary  need  is  not 
going  to  recur,  because  we  are  not  dealing  with  a 
chronic  difficulty  like  extravagance  or  alcoholism, 
which  will  recur  and  cannot  be  checked  by  money. 

3.  On  the  whole,  the  safest  form  of  giving  that  I 
know,  that  which  is  surest  to  perpetuate  itself,  to  be 


166  SOCIAL  WORK 

planted  like  a  seed  and  go  on  without  our  having  to 
stand  by  it,  is  giving  information  —  a  cold-sounding 
thing,  but  sometimes  very  useful.  One  difference  be- 
tween the  social  worker  and  the  person  for  whom 
she  works  ought  to  be  that  the  social  worker  has  had 
more  education,  more  freedom,  more  friends,  more 
opportunity  to  look  around  the  world  and  see  re- 
sources. Hence,  when,  for  instance,  she  comes  to  find 
a  job  for  a  man,  the  social  worker,  because  of  the 
perfectly  undeserved  blessings  that  she  happens  to 
have,  ought  to  be  in  a  position  to  give  information 
that  is  of  value. 

One  of  the  most  precious  kinds  of  information  is 
information  how  to  secure  more  information.  The 
difference  between  uneducated  people  and  those 
whom  we  call  educated,  is  not  that  the  latter  know 
very  much,  but  that  if  they  do  not  know  something 
they  know  how  to  go  to  one  who  does.  The  unedu- 
cated person  is  helpless  to  improve  his  education.  He 
does  not  know  and  cannot  find  out  how  to  look  up  a 
subject. 

I  have  distinguished  information  from  education. 
Information  as  such  never  changes  character  in 
my  opinion.  This  subject  has  been  discussed  in  re- 
cent years  in  connection  with  what  some  call  quite 
falsely  sex  hygiene.  Information  biological,  patho- 
logical, physiological,  talks  about  health  and  dis- 
ease, never  kept  any  man  or  woman  straight  mor- 
ally. It  never  changes  character.  So  our  pubhc  school 
education  sometimes  represents  only  information. 


SOCIAL  THERAPEUTICS  167 

only  the  facts,  not  the  meaning,  the  interpretation, 
the  use  of  those  facts.  Hence  the  pubUc  school  is 
justly  open  to  the  criticism  brought  upon  it  by  those 
who  say  that  it  does  a  child  no  lasting  good  to  know 
facts.  It  may  make  him  clever  and  so  able  (hke 
German  science  in  war)  to  do  more  harm  than  if  he 
knew  less. 

But  when  we  give  education  —  for  example,  hy- 
gienic or  economic  education  —  we  give  something 
else  than  information.  Education  is  that  which,  by 
reason  of  practice,  by  doing  something  again  and 
again,  and  doing  it  if  possible  in  the  presence  of  a 
good  model  (living  or  dead,  book  or  person),  changes 
our  character  and  our  habits,  as  the  use  of  a  muscle 
changes  the  muscle.  A  person  learns  to  write.  That 
is  not  merely  information  —  he  has  learned  to  do 
something.  Learning  to  swim  is  not  information.  We 
learn  it  by  practice,  by  doing  it,  and  by  the  imitation 
of  good  models.  How  does  one  learn  to  think?  By  do- 
ing the  thing,  and  if  there  is  any  model  in  sight,  by 
trying  to  imitate  that  model. 

4.  Education  is  what  social  workers  try  to  give 
most  often,  most  consciously,  over  the  longest  time, 
and  sometimes  with  the  greatest  results.  We  try  to 
give  people  hygienic  education.  We  try  to  give,  not 
merely  hygienic  information,  but  motives  fit  to  bring 
about  a  change  in  habits,  a  wholly  different  thing, 
and  one  which  may  be  of  signal  value.  We  try  to  teach 
self-control,  the  control  of  sleep,  the  control  of  emo- 
tion, the  control  of  appetite.  It  is  hard,  but  it  can  be 


168  SOCIAL  WORK 

done  by  prolonged  effort,  under  such  influences  as 
give  us  courage  to  work  at  it.  We  try  to  give  eco- 
nomic education,  the  power  of  foreseeing  what  is 
going  to  happen  by  reason  of  what  has  happened 
before.  People  are  extraordinarily  prone  to  forget 
things  which  they  do  not  want  to  remember.  We 
may  help  people  by  economic  education,  to  eco- 
nomic foresight,  to  economic  organization  of  their 
resources  by  practice,  and  by  going  over  with  them 
the  cases  of  other  people  who  have  won  out  in  simi- 
lar difTiculties. 

5.  Anybody  who  does  much  talking  is  asked  a  good 
many  times,  "Won't  you  please  come  round  this 
evening  and  just  give  us  a  little  inspiration?"  There 
is  no  request  that  I  look  on  more  sadly,  more  wist- 
fully, than  I  do  on  that.  I  know  how  little  good  such 
"inspiration"  usually  is  because  it  can  be  given  the 
same  way  as  money  or  morphine  can  be  given.  In- 
spiration or  courage  means  emotion  of  some  kind. 
Nobody  believes  in  emotion  more  than  I  do.  I  be- 
heve  the  greatest  hfe  is  the  life  that  feels  the  most, 
enjoys  the  most,  suffers  the  most.  But  emotion  is  one 
of  the  most  transient  and  unrehable  of  states.  One 
may  be  in  a  most  exalted  and  courageous  state  of 
mind  at  the  end  of  a  lecture,  and  a  few  hours  later 
be  as  weak  as  an  invahd,  because,  though  courage 
has  come,  it  is  courage  which  does  not  provide  for 
its  reenforcement,  for  a  new  supply.  We  never  give 
people  help  that  has  any  permanence  except  when 
we  give  them  reahty.  We  try  at  first  to  help  people 


SOCIAL  THERAPEUTICS  169 

in  their  woes  through  our  own  personahties.  But  we 
are  not  strong  enough  to  keep  anybody  else  afloat. 
We  have  to  transmit  something  greater  than  our- 
selves, if  possible  to  bring  people  in  touch  with  a  life- 
preserver  that  will  be  there  after  we  are  gone. 

I  suppose  that  when  we  can  teach  people  to  work 
and  give  them  something  they  can  practise  all  their 
lives  and  get  joy  out  of,  when  we  teach  people  to 
play,  to  deal  rightly  with  their  affections,  and  to  wor- 
ship, we  have  given  realities  permanently  buoyant. 

Our  social  history  cards  at  the  Red  Cross  Refu- 
gees' Dispensary  in  Paris  had  a  great  many  blanks 
on  them,  which  represented  the  blanks  in  our  knowl- 
edge of  the  patients  and  the  defects  of  our  social 
work.  We  rarely  entered  deeply  into  our  patients' 
lives  in  relation  to  their  education,  family  life,  rec- 
reation, religion.  In  our  work  at  that  Dispensary 
we  dealt  chiefly  with  medical  facts  and  economic 
facts.  To  go  thus  far  and  no  farther  cannot  satisfy 
many  nor  remake  lives.  That  Dispensary  was  open 
but  a  few  months  and  within  that  time,  of  course, 
nobody  could  expect  us  to  enter  into  intimate  rela- 
tions with  a  human  being's  life.  But  if  we  were  to 
work  in  any  Dispensary  for  years  and  stfll  not  one  of 
those  cards  had  any  note  about  the  patient's  edu- 
cation, recreation,  family  relationships,  and  religion, 
I  should  feel  that  we  had  failed.  I  should  feel  not 
only  that  we  had  done  superficial  work  (that  is  often 
inevitable),  but  that  we  had  done  nothing  but  super- 
ficial work,  which  is  not  satisfactory. 


170  SOCIAL  WORK 

It  is  because  we  want  to  give  people  the  best,  not 
that  we  have  but  that  the  world  contains,  that  we 
should  have  spaces  on  our  social  history  card  for 
notes  about  those  things  which  we  beheve  are  fun- 
damental in  our  own  lives  and  which  we  want  there- 
fore to  see  constructed  or  increased  in  somebody  else. 

Social  treatment,  then,  is  chiefly,  the  giving  and 
building  of  health,  pleasure,  money,  beauty,  in- 
formation, education,  courage.  It  is  not  because  we 
have  such  a  tremendous  stock  of  those  goods  to  give 
away,  but  because  we  know  that  we  must  somehow 
help  a  person  to  self-help  in  those  directions  or  else 
be  superficial,  that  I  have  phrased  social  treatment 
in  those  terms. 

4.  Creative  listening  in  social  treatment 

One  of  the  simple  and  yet  honestly  useful  things 
that  we  can  do  in  social  work  is  to  give  a  man  a  hear- 
ing. Often  he  will  solve  his  own  problems  with  the 
aid  of  a  Httle  information  from  one  w^hom  he  trusts 
and  has  talked  things  out  with.  But  this  imphes  un- 
usual powers  of  hstening  on  the  social  worker's  part. 
It  imphes  what  Mr.  R.  H.  Schauiller  calls  creative 
listening.  Some  of  the  most  dehghtful  friendships  are 
those  one  makes  through  a  magazine.  In  the  "  Atlan- 
tic Monthly  "  some  years  ago  I  saw  an  article  on 
playing  string  quartets  by  a  man  whom  I  had  never 
heard  of,  Mr.  Robert  H.  SchaufHer.  Mr.  Schauffler's 
WTitings,  which  I  came  to  know  through  this  article, 
contain  many  interesting  points,  but  nothing  so  val- 


SOCIAL  THERAPEUTICS  171 

uable  to  me  as  the  essay  on  "The  Creative  Lis- 
tener." 1  It  was  founded  upon  an  autobiographical 
incident.  As  a  musical  amateur  he  used  to  attend 
orchestral  concerts  in  what  was  then  his  home  city, 
Chicago.  He  used  to  go  with  a  certain  group  of 
friends,  his  brother  and  others,  who  liked  to  sit  to- 
gether because  they  found  that  in  this  way  they  en- 
joyed the  music  more.  Ordinarily  they  were  very 
regular  in  their  attendance.  But  one  evening  for 
some  reason  they  had  to  miss  the  concert,  and  then 
it  came  to  their  knowledge  that  the  orchestra  had 
felt  their  absence  very  much,  and  really  could  not 
play  their  best  without  them.  This  is  true.  There  are 
people  whose  attention  makes  us  play  or  speak  or 
act  better  than  we  could  otherwise.  We  have  known 
it  in  friendship.  We  all  know  that  some  people  when 
we  talk  with  them,  make  us  feel  as  if  we  really  were 
worth  something,  had  some  ideas.  Others  are  de- 
structive listeners  who  make  us  feel  as  if  we  had  no 
ideas;  our  personality  seems  destroyed. 

I  think  it  is  perfectly  within  the  province  of  any 
of  us  to  make  himself  more  of  a  creative  listener 
than  he  has  been  before.  For  creative  listening  is  due 
in  part  to  the  intensity  of  our  sympathy,  the  whole- 
heartedness  with  which  for  the  time  being  we  give 
ourselves  to  the  person  we  are  with. 

Under  favorable  conditions  the  power  of  the  crea- 
tive hstener  to  enlarge  and  to  remake  a  personahty 

1  In  the  volume  called  The  Musical  Amateur.  (Houghton  Mifflin 
Co.,  Boston.) 


172  SOCIAL  WORK 

is  not  capable  of  limit.  The  people  whom  I  most 
often  help  are  the  people  for  whom  I  do  nothing. 
They  tell  their  tale,  spread  it  all  out  before  me;  then 
they  see  the  solution  themselves.  Just  to  state  our 
difficulties  clearly  to  another  person  who  wdll  listen 
not  merely  sympathetically  but  creatively,  and  with 
resistance  as  well  as  furtherance,  is  of  value.  With 
certain  people  we  run  against  a  stone  wall  every 
now  and  then,  even  though  they  are  only  hstening 
silently.  This  is  right  and  helpful.  The  right  kind  of 
listening  is  s^inpathetic  when  it  ought  to  be  and  dis- 
senting when  it  ought  to  be. 

We  help  people  out  of  trouble  in  other  ways  also; 
often  by  bringing  new  facts.  A  person  tells  us  about 
his  difficulties  at  work.  He  sees  it  perhaps  more 
clearly  after  he  has  talked  about  it.  But  he  may  not 
know  some  facts  that  we  know,  and  therefore  we 
may  be  able  to  help  in  some  ways  that  go  beyond 
creative  listening.  But  in  the  end  a  person  has  to 
make  his  O'^ti  decision,  to  find  his  own  solution;  and 
in  many  cases  he  will  find  it  without  any  more  active 
or  physical  help  than  this. 

5.  The  case-workefs  pyramid  in  social  treatment 

It  might  well  be  objected  by  any  thoughtful 
reader  that  if  a  person  carried  out  the  physical,  eco- 
nomic, mental,  moral,  spiritual  investigations  that  I 
have  suggested  in  this  book,  he  could  take  care  of  no 
more  than  one  patient  at  a  time,  and  would  need 
years  to  finish  up  the  tasks  suggested  by  the  history 


SOCIAL  THERAPEUTICS  173 

of  that  one  person.  That  is  an  objection  that  cer- 
tainly deserves  an  answer.  I  will  begin  my  answer  by 
a  comparison  with  medical  work.  A  trained  physi- 
cian is  supposed  to  know  something  of  all  the  or- 
gans in  the  body.  Even  a  dentist  or  an  oculist  has 
had  some  training  on  all  the  bodily  organs  and  not 
merely  on  the  special  ones  he  treats.  Among  the  or- 
gans of  the  body,  the  medical  profession  is  supposed 
to  include  the  brain  and  all  the  functions  of  the 
brain.  This  imphes  that  he  is  supposed  to  have  at 
his  finger-ends  the  ability  to  make  an  examination 
so  complete  that  a  whole  day  would  be  needed  to 
finish  it.  Obviously  if  he  attempted  anything  like  that 
he  would  soon  be  overwhelmed.  But  on  the  other  hand 
if  he  limits  himself  to  the  professional  examination 
of  a  single  organ,  the  one  perhaps  which  the  patient 
complains  of,  he  does  so  at  his  peril.  He  is  in  danger 
of  making  a  wholly  wrong  diagnosis.  But  that  can 
be  diminished  only  in  proportion  to  his  knowledge 
of  all  the  other  organs  that  he  does  not  examine.  A 
well-trained  physician  must  and  can  safely  do  some 
superficial  work.  So  a  very  well-trained  social  worker 
can  and  must  do  some  superficial  social  work.  In  the 
practice  of  any  doctor  who  counts  up  a  month's  pa- 
tients we  will  say  to  one  hundred,  there  will  be  about 
fifty  that  he  has  examined  and  treated  very  slightly. 
Then  there  may  be  twenty-five  whom  he  knows  a 
little  more  about,  fifteen  perhaps  that  he  could  give 
a  full  account  of,  and  possibly  ten  whom  he  has  had 
to  study  from  all  the  points  of  view  that  his  medical 


174  SOCIAL  WORK 

education  has  made  possible  for  him.  His  profes- 
sional life  then  is  not  wholly  superficial  yet  does  not 
attempt  to  deal  exhaustively  with  every  case. 

As  I  see  it,  therefore,  our  work  in  the  social  or 
medical  field  ought  to  be  something  Uke  a  pyramid. 

Thoroughly  studied  cases. 


Superficially  studied  cases. 

We  should  study  and  treat  many  cases  superficially, 
a  smaller  number  more  intensively,  and  at  the  top  of 
the  pyramid  which  represents  our  case-work  will 
come  a  few  to  which  days  or  weeks  of  time  are  de- 
voted. Such  a  distribution  of  time  is  not  unsatisfac- 
tory or  slipshod  because  not  all  the  needs  that  come 
to  our  attention  call  for  thorough  study. 

Such  a  pyramidal  distribution  of  our  energies  is 
familiar  and  satisfactory  in  other  fields  of  life,  for  in- 
stance in  the  field  of  friendship.  Nobody  wants  only 
intimate  personal  relations.  Everybody  needs  as  a 
basis  a  host  of  acquaintances.  Out  of  them  all  he 
makes  a  few  friends  whom  he  hopes  to  know  as  well 
as  he  can  know  any  human  being.  Almost  no  one  is 
satisfied  to  possess  only  acquaintances  or  only  in- 
timate friends.  The  properly  balanced  life  has  both. 

Both  among  those  for  whom  we  attempt  only 
slight  study  or  slight  service,  and  among  those  to 
whom  we  devote  ourselves  intensively,  doctor  and 
social  assistant  alike  must  count  failures  as  well  as 
successes.  We  do  not  try  to  balance  failures  and  sue- 


SOCIAL  THERAPEUTICS  175 

cesses  if  we  are  wise.  The  Lord  only  knows  which  of 
our  seeming  failures  are  really  successes  and  which 
of  our  successes  are  failures.  Some  of  the  people  with 
whom  we  seem  to  have  made  total  failures,  a  more 
complete  knowledge  might  show  to  have  been  actu- 
ally helped.  All  this  we  must  face  from  the  start. 
Then  we  shall  not  be  disappointed  because  we  have 
to  touch  a  great  many  people  superficially  and  to 
fail  a  great  many  times.  That  is  all  right  so  long  as 
we  are  not  always  superficial  and  do  not  always  fail. 
Such  a  philosophy  is  my  defence  for  so  elabo- 
rate and  extensive  a  scheme  of  social  investigation 
and  social  treatment  as  I  have  tried  to  explain  in 
this  book.  The  experienced  physician  and  the  well- 
trained  social  assistant  can  judge  with  some  accu- 
racy which  cases  to  select  for  thorough  study  and 
continued  devotion.  But  such  a  judgment  is  impos- 
sible unless  one  keeps  always  ready  in  the  back- 
ground of  one's  mind  the  v/hole  apparatus  of  social 
diagnosis  and  treatment  as  it  might  be  applied  in 
toto,  if  time  and  strength  were  unlimited. 


CHAPTER  IX 

THE  MOTIVE  OF  SOCIAL  WORK 

What  is  the  motive  of  social  work?  Why  do  we  do  it? 
Why  is  it  worth  while?  What  will  keep  it  going? 

To  me  it  seems  hke  a  head  of  energy  behind  a  fau- 
cet or  behind  a  dam,  a  pressure  that  has  to  be  ex- 
plained; and  as  we  use  the  word  motive,  we  may  well 
think  of  it  in  a  literal  sense  as  something  that 
pushes,  something  that  moves.  Then  what  moves? 
Energy,  which  is  the  source  of  our  work,  is  perhaps 
the  most  general  term  that  there  is  in  the  world.  Be- 
hind eveiy thing,  we  say,  there  is  energy.  Behind  the 
activities  of  our  physical  bodies  there  is  energy  to  an 
extent  that  those  who  have  not  studied  medicine  or 
other  physical  sciences  do  not  always  recall. 

Eighty  per  cent  of  any  human  being's  body  is 
made  up  of  water.  Where  did  it  come  from?  It  came 
from  what  he  has  taken  in  in  the  form  of  drink. 
Where  did  that  come  from?  From  the  earth  and  the 
streams.  Where  did  they  get  it?  From  the  clouds. 
Where  did  the  clouds  get  it?  From  the  seas.  Where 
did  the  seas  get  it?  From  the  interplanetary  spaces 
and  God  knows  where.  Eighty  per  cent  of  our  bod- 
ies, of  our  available  energy,  comes  out  of  something 
as  far  off  as  that,  out  of  sources  that  have  ultimately 
as  little  to  do  with  us  as  that. 

The  other  twenty  per  cent,  the  solids  of  every 


THE  MOTIVE  OF  SOCIAL  WORK    177 

organ  in  our  body,  the  brain  included,  are  alike 
widely  distributed  in  source.  We  do  not  always  stop 
to  think  how  widely  distributed  are  the  foods  out 
of  which  the  body's  sohds  are  built.  Grains,  fruits, 
vegetables,  meats,  we  get  them  out  of  every  part  of 
the  globe.  The  minerals  that  are  deposited  in  us  as 
what  we  call  bone,  the  lime  and  other  salts,  are  some- 
thing which  a  plant  once  sucked  up  out  of  the  earth, 
or  another  animal  took  out  of  his  food  to  pass  on  to 
us.  The  bones  of  a  human  being  come  out  of  the 
bones  of  the  earth  through  his  food,  animal  and  veg- 
etable. The  breath  of  the  trees,  the  oxygen  which 
the  trees  give  out  every  day  and  every  night,  we 
breathe  in.  They  take  up  in  turn  the  carbon  that  we 
give  out,  so  that  there  is  constantly  an  exchange  be- 
tween the  animal  and  vegetable  kingdom  and  ours. 
We  are  warmed  by  inheritance  from  thousands  of 
years  in  the  coal  that  plants  have  laid  down  their 
lives  in  layers  and  strata  to  form;  we  are  warmed 
also  by  the  constant  hteral  burning  up  of  food  en- 
ergy in  ourselves.  We  are  clothed  with  borrowings 
from  sheep  and  cows  and  other  animals;  birds'  feath- 
ers go  to  make  our  pillows,  beds,  and  hats. 

Sometimes  I  wonder  whether  we  are  worth  all 
this  destruction  and  all  the  other  forms  of  destruc- 
tion whose  living  incarnation  we  are.  I  described,  in 
speaking  of  fatigue  and  rest,  how  our  physical  life  is 
a  constant  process  of  burning  up  and  breaking  down 
tissue,  hence  of  destruction.  And  of  course  the  money 
and  labor  of  our  parents  that  kept  us  alive  up  to  the 


178  SOCIAL  WORK 

time  that  we  call  ourselves  self-supporting,  repre- 
sents other  stores  of  energy  passed  on  through  vari- 
ous way-stations,  by  the  same  sort  of  borrowing, 
from  every  part  of  the  universe. 

All  that  death,  that  suffering,  that  destruction, 
are  we  worth  all  that?  One  certainly  could  see  a 
tragic  aspect  to  this  question  if  one  were  so  minded. 
Many  philosophers  have  so  seen  it.  But  the  answer 
depends,  I  think,  on  what  we  do  with  that  energy. 
It  may  easily  be  wasted.  It  may  just  run  through  us, 
as  much  of  our  information  runs  through  us,  un- 
caught,  unused,  sacrificed  for  us,  and  nothing  come 
of  it.  But  it  may  be  used  right. 

When  we  come  to  think  of  our  mental  energies, 
are  we  any  less  incurably  borrowers,  incurably  in- 
debted to  the  universe,  incurably  wasters  except  in 
so  far  as  we  make  use  of  what  we  borrow?  Anybody 
who  has  not  studied  how  the  child  learns  to  talk, 
does  not  realize  what  a  borrowing  the  simplest  acts 
of  language  are,  what  imitators  we  are  from  the  ear- 
liest moments  of  our  lives.  And  if  we  try  to  think 
back  to  the  pieces  out  of  which  we  have  been  actu- 
ally made,  our  intellectual,  moral,  spiritual  hfe,  we 
could  take  ourselves  apart  like  a  piece  of  machinery 
and  say  where  each  piece  came  from.  If  we  look  into 
the  generation  of  our  own  minds  I  think  we  shall  be 
overcome  with  wonder  as  I  often  have  been,  by  the 
consideration  of  how  little  there  is  left  that  is  us  if 
we  take  out  what  has  been  given  us.  I  can  say  from 


THE  MOTIVE  OF  SOCIAL  WORK    179 

vhom  every  idea  I  have  had  came,  from  whom  I  had 
t  as  a  free  gift.  I  beheve  the  greatest  of  all  our  bor- 
'owings  are  from  people  we  never  saw,  from  books, 
rom  music,  from  art,  from  personalities  to  whom  we 
eel  inexpressibly  near  although  we  never  saw  them 
n  the  flesh. 

Our  spiritual  borrowings  are  not  only  from 
iources  such  as  I  have  mentioned,  but  from  imper- 
lonal  sources  also,  from  beauty,  from  nature,  that 
loes  not  speak  to  us  through  any  man.  I  have  seen 
I  hepatica  on  a  rocky  hillside  under  brown  oak 
eaves,  the  sight  of  which  made  me  conscious  that  I 
;ould  never  pay  off  my  debts  for  life.  I  have  heard 
I  thrush  singing  in  the  early  morning  in  wet  dark 
voods,  and  known  then  and  there  that  after  the  gift 
)f  that  song  I  could  never  get  even  with  the  uni- 
verse. 

Most  of  us  have  had  that  sort  of  experience  many 
imes;  it  goes  on  and  on  piling  up  our  debt.  But  our 
)bligation  grows  and  grows  when  we  think  of  our 
country,  of  the  traditions  of  our  race,  and  of  what 
las  been  given  us  by  the  church  or  university  or 
amily  in  which  we  have  found  ourselves  without 
)ur  doing  anything  about  it.  What  should  we  be 
vithout  those?  What  shred  of  personality  would  re- 
nain?  I  do  not  think  the  figure  of  the  body,  as  I 
lave  tried  to  describe  its  borrowings,  is  any  more 
jtriking  than  that  of  the  mind,  the  spirit,  and  the  in- 
ixhaustible  debts  that  it  has  laid  up. 

All  this  energy  poured  into  us  from  the  material 


180  SOCIAL  WORK 

and  from  the  spiritual  universe  around  us  accumu- 
lates in  us.  It  accumulates  bodily  in  vital  force,  zest, 
animal  spirits,  or  "pep";  the  desire  to  shout  and 
sing  or  jump  or  slap  somebody  on  the  back.  That  is 
the  vital  side  of  our  unexpended  borrowings,  the 
bodily  expression  of  the  fact  that  we  have  received 
more  than  we  can  easily  take  care  of.  But  mental 
energy  accumulates  too;  and  the  sense  of  its  pressure 
is  expressed  in  what  seems  to  me  the  greatest  word 
in  our  language  —  gratitude.  Gratitude  is  "happi- 
ness doubled  by  wonder,"  happiness  such  as  any- 
body may  contain  almost  unconsciously  or  may  let 
out  of  him,  if  he  is  thoughtful,  in  action  sprung  from 
conscious  gratitude.  Gratitude  seems  to  me  ulti- 
mately the  motive  of  social  work.  We  find  in  our- 
selves this  painful  head  of  energy  —  to  me  often 
painful.  The  sense  of  an  animal  caged,  of  a  dog  in 
leash,  is  the  figure  that  most  often  comes  to  me  as  I 
am  aware  of  what  has  been  given  to  me  and  of  how 
little  I  have  paid  it  back.  The  extra  flood  of  physical 
energy  which  any  healthy  human  being  or  animal 
has,  is  paralleled  in  this  tension  of  gratitude  for  all 
the  gifts  which  we  have  not  properly  handed  back, 
have  not  passed  on,  and  never  shall. 

The  attempt  to  pay  out,  to  pass  on,  this  energy 
naturally  divides  itself  up  according  to  the  ways  in 
which  we  have  received  it.  We  have  received  the 
physical  bounty  of  hfe.  We  know  how  good  it  is  to 
get  water  when  we  are  thirsty  and  food  when  we  are 
hungry,  and  along  with  the  full-flavored  awareness 


THE  MOTIVE  OF  SOCIAL  WORK    181 

of  this  good  we  feel  the  pain  of  not  being  able  to 
share  it  as  swiftly  as  we  would  like  to  share  it,  as 
fully  as  we  would  Uke  to  share  it,  with  people  who 
have  not  got  what  we  have.  We  call  that  pity,  the 
sense  of  kind.  I  think  of  it  as  the  sense  of  a  common 
need.  Other  people  are  such  as  we.  We  are  painfully 
aware  of  what  has  been  given  to  us,  and  how  much 
we  and  everybody  else  need  it,  and  how  little  we  de- 
serve it.  We  are  eager  therefore  to  pass  that  on  in 
any  such  form  as  it  can  be  received.  We  are  grateful 
for  any  good  chance  to  pass  it  on.  A  homely  but  true 
image  is  that  of  the  nursing  mother.  The  baby  needs 
milk  and  the  mother  needs  to  get  rid  of  that  milk.  It 
is  a  painful  pressure  in  her  breast  and  a  pressing 
need  in  her  child.  The  two  needs  meet  and  satisfy 
each  other. 

We  are  just  as  eager,  I  think,  to  give  back  in  kind 
all  the  different  sorts  of  delight  and  of  beauty  for 
which  we  are  grateful.  But  we  have  not  well  ex- 
pressed this  eagerness.  I  have  dwelt  already  on  the 
great  lack  of  beauty  and  of  art  in  social  work,  on  its 
ugliness  and  drabness,  and  on  the  care-worn  look  in 
the  social  worker's  face.  But  no  one  who  is  vividly 
conscious  of  the  gifts  of  beauty  which  have  come 
into  his  o\\ti  life  can  continue  to  make  his  attempts 
at  social  work  as  unbeautiful  as  they  have  been  hith- 
erto. 

If  we  have  any  sense  of  gratitude  to  the  people 
that  have  cared  for  us,  we  want  to  pass  on  affection. 
We  know  the  affection  that  was  our  physical  crea- 


182  SOCIAL  WORK 

tion  in  the  beginning  and  our  upbringing  through 
childhood  and  youth,  yet  most  of  us  have  never 
tried  through  most  of  our  hves  to  pay  back  these 
debts  to  our  parents.  Indeed  we  usually  do  not  be- 
come aware  of  those  debts  until  it  is  too  late.  To 
know  that  would  bring  us  to  almost  insupportable 
remorse  after  our  parents  have  left  us,  if  we  were  not 
aware  that  we  could  pay  over  to  somebody  else  the 
affection  and  care  which  they  once  lavished  on  us. 

As  we  know  that  the  physical  energies  of  water 
and  oxygen  and  carbon,  of  the  food,  the  lime  salts, 
and  whatever  else  goes  to  make  up  our  physical  be- 
ing, all  come  out  of  one  source,  so  we  are  aware  that 
all  spiritual  gifts  come  out  of  one  and  the  same 
source.  To  be  vividly  aware  of  that,  to  stop  and  face 
the  facts,  to  stop  and  take  a  view  of  where  we  are, 
tells  us  what  next  to  do.  It  makes  us  eager  to  pay 
back  some  of  that  gratitude  directly  in  prayer,  and 
also  indirectly  through  all  the  way  stations  by 
which  this  help  has  come  to  us.  If  you  want  to 
please  a  mother  you  do  something  for  her  children. 
A  human  being  lives  in  his  children,  in  the  people  or 
the  undertakings  that  are  his  children  Uterally  or 
figuratively.  If  you  love  him,  you  feed  his  lambs.  So 
we  get  the  impulse  to  pass  on  the  best  fruits  of  life, 
first  to  the  one  source  of  all  that  makes  us  grateful, 
and  then  to  the  children  of  this  central  Energy,  the 
different  way  stations  from  which  it  has  come  to  us. 

We  eat  our  heads  off  like  stabled  horses  with  too 


THE  MOTIVE  OF  SOCIAL  WORK    183 

much  oats,  if  we  do  not  get  a  chance  to  give  away 
some  of  what  has  come  to  us.  A  man  who  tells  funny 
stories  is  always  grateful  to  the  man  who  will  hsten 
to  him.  The  same  principle  holds  true  all  the  way 
from  story-telUng  to  social  work.  It  can  be  taken  as 
humiliating,  but  properly  viewed  it  is  a  sanifying 
and  humbhng  fact. 

I  wrote  a  moment  ago  of  the  sense  of  what  we  owe 
to  our  parents,  a  debt  that  seems  almost  insupporta- 
ble sometimes.  It  would  be  insupportable  if  we  could 
not  pay  it  on  to  somebody  else.  Were  it  not  for  this 
central  fact  our  gratitude  would  be  a  curse  not  a 
blessing.  But  in  fact  those  who  gave  to  us,  our  par- 
ents and  all  the  rest,  are  best  pleased  if  we  pay  over 
their  gifts  to  somebody  else.  That  is  how  we  can  best 
repay  them. 

If  this  is  a  right  conception  of  the  source  out  of 
which  comes  the  energy  that  has  set  us  going  and 
will  keep  us  going,  I  think  we  can  trace  out  a  jus- 
tification for  the  principles  of  social  work  which  I 
have  tried  to  present  in  this  book  and  will  now  sum- 
marize: 

1.  We  want  to  do  social  work  because  we  have  got 
something  that  we  must  share,  something  that  is  too 
hot  to  hold.  There  is  a  false  emphasis,  approaching 
sentimentahty,  in  saying  that  our  social  work  is  done 
because  of  our  love  for  the  individual  people  to 
whom  we  give.  We  have  a  hope  that  some  day  we 
may  know  a  few  of  these  people  well  enough  to  say 
that  we  love  them.  But  that  is  hope,  not  fact  or  pres- 


184  SOCIAL  WORK 

ent  impulse.  Hence  it  is  not  right  (although  it  is  not 
a  fearful  error)  to  say  that  we  do  social  work  for  love 
of  the  particular  individuals  whom  we  try  to  help. 
We  are  looking  for  an  opportunity  and  are  grateful 
for  the  opportunity  that  social  work  gives  us,  to 
pass  on  the  gifts  which  we  are  grateful  for,  not  as  has 
sometimes  been  said,  to  people  whom  we  love  but  to 
every  one  who  needs  them. 

That  may  seem  a  very  slight  difference  of  em- 
phasis. I  think  it  is  a  very  important  difference  of 
emphasis.  We  are  in  a  much  more  self-respecting 
position  if  we  do  not  have  to  think  of  ourselves  as 
ha\iDg  ah-eady  conquered  at  the  beginning  that  which 
we  aspire  to  win  in  the  end,  a  personal  affection  for 
all  our  patients.  If  we  remember  that  our  patients 
are  (unconsciously)  doing  us  a  favor  in  allowing  us 
to  pass  on  something  to  them,  and  that  although  we 
may  have  found  a  genuine  need,  stiU  we  are  grateful 
to  them  because  they  want  what  we  have  to  give, 
then  our  work  is  humble  and  free  from  taint  of  Pha- 
risaism. 

2.  The  second  principle  is:  give  as  one  passing  on 
that  which  is  not  our  own.  That  is  famihar  enough  in 
relation  to  money.  Any  one  who  has  any  money  and 
any  capacity  for  thoughtfulness,  knows  that  his 
money  is  not  his  o\vti.  Whether  it  happens  to  be  ht- 
erally  in  trust  or  not,  the  only  right  he  has  is  the 
right  of  rightly  choosing  what  he  will  do  with  it.  He 
holds  it  rightfully  just  so  long  as  he  needs  to  find  the 
chance,  the  best  opportunity  for  passing  it  on. 


THE  MOTIVE  OF  SOCIAL  WORK    185 

Such  a  sense  of  trusteeship  we  ought  to  feel  about 
everything  that  we  have  and  want  to  give:  beauty, 
information,  education,  affection,  and  courage.  One 
should  give  them  (if  he  can !)  not  as  one  who  has  any 
special  merits,  not  as  one  having  property  which  is 
one's  own,  but  as  one  who  has  received  without  any 
possible  deserts  an  incredible  wealth  and  would  Uke 
above  all  things  to  share  it  because  it  is  not  his  own. 

3.  We  ought  to  give  and  build,  because  the  effects 
of  any  giving  that  is  not  also  building  will  not  last. 
Our  bodies  and  our  souls  are  what  they  are  because 
of  what  has  been  given  and  built  into  them  by  nature 
and  by  man.  The  same  energy  which  burns  in  our 
bodies  and  knows  in  our  consciousness  should  make 
us  desire  always  to  give  and  build  by  giving,  be- 
cause we  have  ourselves  been  built  up  of  such  gifts. 

4.  We  ought  to  give  and  take.  That  is  another  as- 
pect of  giving  as  one  who  passes  on.  We  can  give 
only  what  we  have  taken.  Hence  if  we  allow  our 
lives  to  get  cooped  up,  narrow  and  stifled,  so  that  we 
are  not  taking  in  steadily,  or  not  getting  fresh  energy 
out  of  what  we  have  already  taken  in  during  the 
years  that  are  past,  we  soon  have  nothing  to  give.  I 
have  written  of  the  ugliness  and  the  depression  that 
I  have  seen  too  much  in  social  workers'  lives.  That  is 
partly  because  they  are  often  led  into  giving  without 
providing  for  any  adequate  source  of  renewal.  They 
are  not  taking  in  enough  to  have  anything  to  give 
out.  They  give  until  they  are  drained  dry,  squeezed 
out. 


186  SOCIAL  WORK 

5.  We  give  not  as  people  who  find  the  world  so 
pitiable,  so  miserable  that  we  want  to  diminish  its 
misery.  We  give  as  people  who  find  the  world  so 
glorious,  so  overflowing,  in  what  it  has  done  for 
us,  that  we  want  to  even  up,  to  pay  out.  We  want 
to  share  our  enthusiasms.  Pity  led  Schopenhauer  to 
pessimism.  He  pitied  the  world  so  much  that  he 
thought  everybody  ought  to  get  out  of  it  by  suicide. 
Pity  therefore  does  not  necessarily  lead  us  to  social 
work. 

But  if  we  admire  anybody,  that  fact  gives  us  a 
duty  to  get  our  admiration  over  to  somebody,  to 
share  our  enthusiasm.  The  whole  of  a  Christian's 
duty  might  be  phrased  as  the  duty  to  share  his  sense 
of  the  beauty  and  the  wonder  that  is  in  Jesus  Christ. 
Almost  the  only  act  that  we  can  be  sure  will  be  of 
use  in  the  world  is  the  act  of  sharing  what  enthusi- 
asm we  have. 

6.  But  this  cannot  be  done  without  some  care 
to  shape  it,  without  some  labor  to  put  it  in  a  form 
in  which  somebody  else  will  understand  this  sense 
of  our  admiration  or  gratitude.  Without  form  and 
study  to  give  it  form,  our  enthusiasm  is  mere  noise 
and  good  spirits.  As  I  have  described  the  fund  of 
energy  which  comes  into  us,  is  felt  as  gratitude  and 
then  pours  out  of  us  in  social  work,  one  may  have 
wondered,  where  does  man's  individual  will  and 
choice  come  in?  Where  does  he  begin  and  these  tu- 
multuous energies  stop?  What  is  he? 

He  is  that  which  focusses,  that  which  forms,  which 


THE  MOTIVE  OF  SOCIAL  WORK    187 

makes  comprehensible,  which  expresses  the  energies 
that  have  been  given  him  as  a  free  gift.  And  because 
miraculously  he  is  made  new  —  for  everything  that 
is  new  is  a  miracle  —  because  miraculously  he  is 
different  from  every  human  being  that  ever  was,  so 
different  from  all  others  is  the  gift  that  he  has  to 
give.  I  think  it  is  sometimes  comforting  to  look  at 
a  finger-print.  One  gets  doubtful  whether  there  is 
any  special  reason  that  the  individual  called  by  one's 
name  should  persist  on  top  of  the  earth.  Then  it  is 
well  to  go  back  to  simple,  elemental  facts  hke  finger- 
prints, with  the  pretty  nearly  irresistible  conclusion 
that  the  rest  of  our  body  and  soul  must  be  as  unique 
as  that,  and  so  possesses  something  as  original  to 
contribute  to  the  world.  I  have  no  doubt  that  there 
is  waiting  for  each  of  us  to-day  a  job  much  more  in- 
dividual than  we  have  ever  yet  done. 

Although,  then,  we  can  rightly  give  in  social  work 
merely  as  people  who  pass  on  to  others  in  gratitude 
and  wonder  the  energies  which  create  our  bodies 
and  our  souls,  yet  we  can  be  perfectly  sure  that  if  we 
do  what  it  is  up  to  us  to  do,  we  shall  in  time  be  giving 
as  people  never  gave  before  and  never  will  again. 
We  have  missed  rare  chances  in  social  work  unless 
through  presence  of  mind  we  find  our  chance  to  express 
differently  from  what  we  have  ever  heard  it  expressed 
before  that  which  we  feel  pushing  in  us  to  get  out. 

7.  Since  it  is  our  business  to  give  as  people  who 
pass  on,  we  want  if  we  can  to  make  it  clear  sooner  or 
later  to  the  people  to  whom  we  pass  it  on,  that  we 


188  SOCIAL  WORK 

know  this.  Then  they  will  feel  no  shame  in  taking 
since  they  know  that  they  do  not  take  from  us. 
There  will  be  no  sense  that  a  higher  being  is  distrib- 
uting what  a  lower  being  has  to  take,  if  we  make 
it  clear  that  we  are  sharing  that  which  it  is  uncom- 
fortable not  to  share.  We  are  sharing  that  which  we 
share  because  in  view  of  all  the  bounty  which  we 
have  received,  in  view  of  the  beauty  which  has 
struck  us  dumb,  in  view  of  the  flood  of  affection 
that  we  never  have  answered,  we  know  what  to  do 
next.  We  know  that  we  are  branches  of  a  vine,  and 
that  the  sap  of  that  vine  can  flow  out  in  us  and 
through  us  to  other  tendrils. 


THE  END 


CAMBRIDGE  .  MASSACHUSETTS 
U    .    S    .   A 


DUE  DATE 


^     JL 


I  AM  ^S  - 


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5  1991 


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